Acknowledgement

We sincerely express our gratitude to the people behind the completion of this presentation. We would like to express our heartfelt gratitude to the friends and classmates for the support and encouragements you have given us. To our clinical instructors who supervised us during our clinical exposures at Caraga Regional Hospital and Surigao Medical Center and for the guidance and encouragement throughout this case presentation, to maam Jecel Eupea for approving our chosen case, to our ever supportive parents and family for their moral and financial support and motivation. And for the most of all to our Almighty God from whom all the graces flow for the needed guidance and wisdom.

Introduction

Our patient Mr. CJ is a 6 years old preschooler in Cuyago Jabonga, Agusan del Norte. He

was admitted at Caraga Regional Hospital last March 2, 2010, related to Dengue Fever with some DHN, acute gastritis. This prompts the group of choose this case study for us to fully understand the nature of the said disease and the risk involve it; hoping that we can contribute something to lessen its occurrence through educating the community people about its etiology, treatment and preventions. This case is both beneficial to the nursing students as the care providers and to the community people as recipients of care. In one way or another both parties involved in the said case so that both of them need to work hand in hand for its eradication. It is indispensible for our local health care delivery system to continue disseminating information in our community and its neighboring places for the disease prevention. As they always say an ounce of prevention is better than a pound of cure.

Review of Related Literature

Dengue Fever

Dengue fever is an infectious disease carried by mosquitoes and caused by any of four related dengue viruses. This disease used to be called break-bone fever because it sometimes causes severe joint and muscle pain. Dengue Fever is a flu-like illness spread by the bite of an infected mosquito and an acute febrile viral disease characterized by sudden onset, fever of 3-5 days, intense headache, myalgia, anthralgic retro-orbital pain, anorexia, GI disturbances and rash.The viruses are transmitted to man by the bite of infective mosquitoes, mainly Aedes aegypti. The incubation period is 4-7 days (range 314 days). Sign and Symptoms of Dengue Fever

Chills Headache Pain upon moving the eyes Low backache Painful aching in the legs and joints Fever (temperature rises as 104 F (40 C))with relative low heart rate (bradycardia) and low blood pressure (hypotension) The eyes become reddened A flushing or pale pink rash comes over the face The glands (lymph nodes) in the neck and groin are often swollen The palms and soles may be bright red and swollen

How is Dengue Fever diagnosed? A doctor or other health care worker can diagnose dengue fever by doing a blood test. The test can show whether the blood sample contains dengue virus or antibodies to the virus. In epidemics, dengue is often clinically diagnosed by typical signs and symptoms. When to go for dengue test If one has persistent fever for more than two days then one should go for CBC (Complete Blood Count) check up. If the platelet count and WBC count are below than there usual range one should go for a dengue antigen test. If one has continues fever for more than two days and / or constant headaches one should go for CBC check up. And one should decide whether to go for dengue test depending on the result of CBC counts. Etiology Dengue fever is cause by dengue virus (DENV), mosquitoborne flavivirus. DENV nssRNE positive strand virus of the family flaviviradae; genusflavivirus. There are four
3

serotype of DENV. The virus has a genome of about 11000 bases that codes for three structural proteins, C, prM, E; seven nonstructural proteins, NS1, NS2a, NS2b, NS3, NS4a, NS4b, NS5; and short non-coding regions on both the 5 and 3 ends. Treatment of Dengue Fever There is no specific treatment for dengue fever, because dengue is caused by a virus and most people recover completely within 2 weeks. To help with recovery, health care experts recommend. Getting plenty of bed rest. Drinking lots of fluids to prevent dehydration. Taking medicine to reduce fever. Platelet transfusions if the platelet level drops significantly (below 20000) or if there are significant bleeding.
Epidemiology

Dengue is transmitted by Aedes mosquitoes, particularly A. aegypti and A. albopictus. Dengue may also be transmitted via infected blood products (blood transfusions, plasma, and platelet), but the scale of this problem is unknown. Prevention Methods of prevention of Dengue fever mentioned in various sources include those listed below. This prevention information is gathered from various sources, and may be inaccurate or incomplete. None of these methods guarantee prevention of Dengue fever.

Avoid mosquito bites Mosquito repellant Protective clothing Window screens Remove water-filled mosquito breeding areas Avoid heavily populated residential areas. When indoors, stay in air-conditioned or screened areas. Use bed nets if sleeping areas are not screened or air-conditioned. Dengue vaccine - not yet available but being researched. If you have symptoms of dengue, report your travel history to your doctor

Prognosis

Most people who develop dengue fever recover completely within two weeks. Some, however, may go through several weeks of feeling tired and/or depressed.

Eco-epidemiological analysis of dengue infection during an outbreak of dengue fever, India

Background
Dengue infection (DI) is amongst the most important emerging viral diseases transmitted by mosquitoes to humans, in terms of both illness and death .The worldwide large-scale reappearance of dengue for the past few decades has turned this disease into a serious public health problem, especially in the tropical and subtropical countries .It is estimated that 52% of the global population are at the risk of contracting Dengue fever (DF) or dengue hemorrhagic fever (DHF) lives in the South East Asian Region. Although all the four serotypes have been circulating in this region, ecological and climatic factors are reported to influence the seasonal prevalence of the dengue vector, Aedes aegypti, on the basis of which countries in this region are divided in to four zones with different DF/DHF transmission potential .In most of the countries, dengue epidemics are reported to occur, during the warm, humid and rainy seasons, which favor abundant mosquito growth and shorten the extrinsic incubation period as well . DF has been known to be endemic in India for over two centuries as a benign and self-limited disease. In recent years, the disease has changed its course manifesting in the severe form as DHF, with increasing frequencies .Delhi City (India) is home to more than 13 million people and is endemic for DI .Overpopulation has consequently led to poor sanitary conditions and water logging at various places. A major epidemic of DHF from Delhi was last reported in the year 1996 after which DI became a notifiable disease and a number of policies were formulated to bring the DI as well as its vector under control. The retrospective studies, one conducted by us during the period, 19972001 and another by National Institute of Communicable Diseases (NICD), New Delhi during the year 1997, have observed a decline in the number of cases having either DF or DHF in the following years .Although, the vector mainly responsible for the spread of DI is present all the year around in Delhi, studies on the relative prevalence and distribution have shown the highest A. aegypti larval indices during the monsoon and post monsoon period . In the year 2003, India had experienced one of the wettest monsoons in 25 years, which led to a spate of mosquito growth creating an alarming situation of mosquito borne diseases in many
5

states. Delhi experienced an outbreak of DF this year, after 6 years of silence. Studies conducted in the countries like Brazil, Indonesia and Venezuela, where DI is present either in epidemic or endemic form have suggested a correlation between weather and pattern of DI. Rain, temperature and relative humidity are suggested as important factors attributing towards the growth and dispersion of this vector and potential of dengue outbreaks .Since limited data is available on the association of climatic conditions and the pattern of DI from this geographical region, this study was conducted to find out the relationship of dengue infection with climatic factors such as the rainfall, temperature and relative humidity during the dengue outbreak in the year 2003. Distribution by age Out of 893 serologically positive cases, 687 cases belonged to the adult's age group (> 12 years) and 206 cases to pediatric age group ( 12 years) in this study. Larger proportions of serologically positive cases were observed among adults, with a positive prevalence of 56.4% among children and 58% among adults, distribution was however, not significantly different when compared with pediatric age group (p > 0.05). The difference between numbers of serologically positive cases among adult and pediatric group in post monsoon period as compared to the rest of the season was also not significant (p > 0.05)

Discussion
In the year 2003, India had experienced one of the wettest monsoons in 25 years, which led to a spate of mosquito growth creating an alarming situation of mosquito borne diseases in Delhi and many other states .As a consequence to this unusually heavy rain, an outbreak of dengue fever was once again reported from Delhi after a silence of six long years. Most of vector borne diseases exhibit a distinctive seasonal pattern and climatic factors such as rainfall, temperature and other weather variables affect in many ways both the vector and the pathogen they transmit .Worldwide studies have proposed that ecological and climatic factors influence the seasonal prevalence of both the A. aegypti and dengue virus .The vector mainly responsible for the spread of DI is present at the basal level all the year around in Delhi, however, studies on the relative prevalence and distribution have shown the highest A. aegypti larval indices during the monsoon and post monsoon period .Since limited data is available on the affect of climatic factors on the pattern of DI, this study was planned to carry out the month wise detailed analysis of three important climatic factors such as rainfall, temperature and relative humidity on the pattern of DI. Observations on the seasonality were based on a single year's data as the intensity of sampling was at its maximum during this outbreak period. The outbreak coincided mainly with the post monsoon period of subnormal rainfall, which was followed, by relatively heavy rainfall during the monsoon period; from June to September 2003. The difference in the total rainfall and temperature during three seasonal periods was found to be statistically significant (p < 0.05). Monthly weather data showed that temperature variations were more amongst different months during the pre monsoon and post monsoon period as compared to the monsoon period. Even though, the monsoon season began in mid- June, there was no respite from the heat as there was not much difference in the temperature during the last month of pre monsoon; May and beginning of monsoon in the June. Unusual heavy rainfall subsequently led to decrease in temperature during the later part of monsoon period. The temperature showed a decline and
6

remained almost constant during the months of July and August (30.2C), continuous heavy rainfall subsequently led to further decrease in the temperature during the month of September to 29C. Relative humidity increased during the rainy season and remained high for several weeks. An in-depth analysis of these three factors thus led to a proposal that optimum temperature with high relative humidity and abundant stocks of fresh water reservoirs generated due to rain, developed optimum conditions conducive for mass breeding and propagation of vector and transmission of the virus. Our study was in tune with a previous study by NICD of seasonal variations and breeding pattern of A. aegypti in Delhi, which showed that there are two types of breeding foci, namely; primary and secondary breeding foci. Primary breeding foci served as mother foci during the pre monsoon period. A. aegypti larvae spread to secondary foci like discarded tyres, desert coolers etc., which collect fresh water during the monsoon period .This study supported the proposal that all the three climatic factors studied could be playing an important role in creating the conducive condition required for breeding and propagation of this vector, the basal level of which is present all round the year. This prospective study therefore highlighted the major important factors, which could alone or collectively be responsible for an outbreak. In our study, the largest proportion of serologically positive cases was recorded in the post monsoon period, which is in agreement with our previous study .Our findings were in coordination with study by other groups from this geographical .The seasonal occurrence of positive cases has shown that post monsoon period is the most affected period in Bangladesh as well .However, a retrospective study from Myanmar during 19962001 reported the maximum cases of dengue during the monsoon period [.Study by group of Rebelo from Brazil has also emphasized the importance of season. They have observed that dengue cases were higher during rainy season showing the importance of rain in forming prime breeding sites for A. aegypti thus spread of DI .Study of eco-epidemiological factors by Barrera et al .showed that DF has a positive correlation with the relative humidity and negative relation with evaporation rate. Peaks of dengue cases were observed to be near concurrent with rain peaks in this study from Venezuela showing a significant correlation of intensity of DI with the amount of rain .In this study we have observed that temperature tends to decrease towards the end of monsoon period, specially remains moreover constant during the later months of rainy season. India and Bangladesh fall in the deciduous, dry and wet climatic zone. The temperature remains high during the pre monsoon period. It is continuous rain pour for a couple of days that brings down the temperature during the monsoon period, which may also be responsible for an increase in the relative humidity and decrease in the evaporation rate thus maintaining secondary reservoirs containing rain water. More studies are needed to establish the relationship between the climatic changes and dengue outbreaks, which would help in formulating the strategies and plans to forecast any outbreak in future, well in advance. Very little dengue is found in adults in Thailand, presumably because people acquire complete protective immunity after multiple DI as children ,as DI is highly endemic in Thailand .On the other hand, DI especially DHF is an emerging disease in India; probably this may be the reason that people of all the age are found to be sensitive to infection in our study. Even though more adults were reported of having anti dengue antibodies, the difference in the number of positive cases was not significant as compared to pediatric age group.The severity of this outbreak was lesser as compared to the DHF epidemic that occurred in year 1996 caused by the serotype Den2 .Serotype Den-2 is reported to be the one mainly associated with DHF, the more severe form of

the disease .More studies in this regard can further elucidate correlation of serotypes with severity of disease from this geographical region.

Conclusion
This prospective study highlighted rain, temperature and relative humidity as the major and important climatic factors, which could alone or collectively be responsible for an outbreak. More studies in this regard could further reveal the correlation between the climatic changes and dengue outbreaks, which would help in making the strategies and plans to forecast any outbreak in future well in advance.

Patient Health History

A. BIOGRAPHIC DATA: Name: Age: Sex: Civil Status: Birth Day: Home Address: Religion: Mr.CJ 6 years old Child Child September 02, 2003 Cuyago, Jabonga, Agusan del Norte Roman Catholic

Nationality: Occupation: B. ADMISSION DATA Hospital: Ward service: Date admission/time: Mode of Admission: Date of discharge:

Filipino Child

Caraga Regional Hospital Pedia ward March 3, 2010 wheelchair March 9,2010

Vital signs upon admission: Weight: Height: Temperature: Pulse Rate: Respiratory Rate: Blood pressure: Chief Complain: Attending Physician: Admitting Physician: Admitting Diagnosis: Final diagnosis: Primary source of data: Secondary source of data: 18 kg 40 38.5 C 88 bpm 25 cpm 110/70 mmHg 3 days fever PTA onset of fever of on and off Dr. Dotor Dra. Ma. Lourdes T. Cubillan R/t Dengue fever with acute gastritis Dengue fever Patient SO and Patients chart

NURSING HEALTH HISTORY

Date of Assessment: Source of Information: March 3, 2010- March 5, 2010 patient, SO and chart

C. HISTORY OF PRESENT ILLNESS Before admission to the hospital the patient experience nausea and vomiting and fever. So, last March 3, 2010 at 10:30 am, patient was rushed to the hospital due to on and off fever and

sudden stomachache to seek medical assurance as verbalized by the grandmother. He was then admitted at Caraga Regional Hospital and referred to the physician.

D. PAST HEALTH HISTORY Mr. CJ experienced childhood illness such as mumps and measles but was not able recall the exact date it occurred. He did not have any poliomyelitis and rubella as claimed by his grandmother. Mr. CJ completed his immunizations in Health Center like BCG, DPT, OPV, Hepa B and Measles. He also experienced cough and fever as verbalized by the SO.
Vaccine Minimum Age at 1st Dose Number of Doses Minimu m Interval Betwee n Doses Reason

BCG

Birth or anytime after birth

BCG given at earliest possible age protects the possibility of TB meningitis & TB infectious in which infants are prone. 4 weeks 4 weeks An early start with DPT reduces the chance of severe pertussis The extent protection against polio is increased the earlier the OPV is given Keeps the Philippine polio free

DPT OPV

6 weeks 6 weeks

3 3

Hep B

At birth

6 weeks interval from 1st dose to 2nd dose, and ; 8 weeks interval from 2nd dose to 3rd dose.

An early start of Hep B reduces the chance of being infected and becoming a carrier. Prevent liver cirrhosis and liver cancer. About 9000 die of compilations of HB. 10% of Filipinos have chronic HB infection.. Eliminate HB before 2012 .

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Measles

9 months

At least 85% of measles can be prevented by immunization at this age. Prevents deaths (2% die), malnutrition, pneumonia, diarrhea (at least 20%) get these compilations from measles) etc. Eliminate measles by 2008.

History of Hospitalization: No past history of hospitalization.

Family health history: Mr. CJ was the youngest among the three siblings. The patients mother was diagnosed due to hypertension and his grandfather diagnosed due to diabtes.

Genogram
S Grandm Grandfath er
other I Fathe B r L I N G S
Mother P

her

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PERSONAL AND SOCIAL HISTORY

LIFESTYLE:
Personal habits: The patient doesnt smoke and drink alcoholic beverages. He likes playing with his friend.

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DIET:
Pre Hospitalization: Mr. CJ, His like to eat fruits and junk foods. Patient usually consumed one cup rice, two hotdogs or one egg and one glass of milk for his breakfast. During lunch time one cup of rice, fried chicken and two glasses of water. During dinner time one cup of rice, one to two slice of adobong baboy and two glasses of water will do. He can consume five to six glasses of water a day. Upon Hospitalization: When patient was hospitalized, his physician ordered diet as tolerated with no colored foods like chocolate, milo and chuckie.

SLEEP & REST PATTERN

Pre- Hospitalization: Patient usually sleeps at 8:00 pm and wake up 7:00 am. He also takes an afternoon nap after lunch for 2 hours with a total of 13 hours of sleep. Upon Hospitalization: His sleeping pattern in the hospital is quite different to his usual routine of sleep. He has difficulty in sleeping since he is always disturbed by itching. Now he usually sleep at 8:00pm, then he will be awaken by 11:00pm and goes back to sleep around 1:00am until 5:00am. In the day time, he sleeps at 9:00am to 11:00 am, 2:00 pm to 3:00pm with a total number of ten hours of sleep.

Elimination Pattern:
Pre- Hospitalization: The frequency of his urination was 5 times a day; 3 times in the morning and 2 times at night. He defecates every morning and has no difficulty in voiding and defecating.

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Upon- Hospitalization: During hospitalization the patient has bathroom privileges.

Activity of Daily Living:

Pre- Hospitalization: The patient will go to the school and at the recess time the patient were eating with his friends and having playing after. After the class he goes home to watch television.

Upon- Hospitalization: Patient has always been on bed most of the time.

Recreation / Hobbies:
The patient is a preschooler in Cuyago, Jabonga, Agusan Del Norte. He was spending his time in canteen and playing with his classmates.

SOCIAL DATA:
Family Relationship/ Friendship With regards to their family relationship, Patient has strong family ties and their parents are very supportive with regards to their studies. He has many friends to play with. Educational Attainment / Socio-economic Data

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In his education, the patient is still a preschooler at Cuyago, Jabonga, Agusan del Norte.

Home and Neighborhood Conditions

Patient resides in Cuyago, Jabonga, Agusan del Norte. He lives in a semi concrete house with 4 bedrooms and a comfort room and has a backyard with plants. At the neighborhood house, lot of hanging clothes, some tire that have water in the inside and some cans that full of water. Their environment has lot of trees.

DEVELOPMENTAL TASK
Growth and Development: The school age, from 6 to 12 years old, in the psychosocial development of Erik Eriksons the Industry vs. Inferiority. From age six years to puberty, children begin to develop a sense of pride in their accomplishments. They initiate projects, see them through to completion, and feel good about what they have achieved. During this time, teachers play an increased role in the childs development. If children are encouraged and reinforced for their initiative, they begin to feel industrious and feel confident in their ability to achieve goals. If this initiative is not encouraged, if it is restricted by parents or teacher, then the child begins to feel inferior, doubting his own abilities and therefore may not reach his potential. According to Freuds Stages of Psychosexual Development, age six to puberty is in Latency stage. During this stage that sexual urges remain repressed and children interact and play mostly with same sex peers.

Vital Signs

Temp PR RR BP

7am-3pm Shift 8 am 12 pm 38.5C 38C 88 bpm 89 bpm 25 cpm 24 cpm 110/70 mmHg 100/70 mmHg

March 3, 2010 3pm-11pm Shift 4pm 8pm 39C 37.1C 90 bpm 90 bpm 22 cpm 24 cpm 110/60 110/70 mmHg mmHg

11pm-7am Shift 12am 4am 38.5C 37.2C 87 bpm 95 bpm 25 cpm 23 cpm 90/60 100/60

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Temp PR RR BP

7am-3pm Shift 8 am 12 pm 38.5C 37.2 C 88 bpm 92 bpm 25 cpm 22 cpm 110/70 mmHg 110/60 mmHg

March 4, 2010 3pm-11pm Shift 4pm 8pm 37.5C 38.1C 95 bpm 98 bmp 21 cpm 22 cpm 100/60 110/60 mmHg

11pm-7am Shift 12am 4am 38.5C 38.4C 96 bpm 94 bpm 23 cpm 23 cpm 100/60 110/70 mmHg mmHg

Temp PR RR BP

7am-3pm Shift 8 am 12 pm 38.5C 37.5C 88 bpm 90 bpm 25 cpm 25 cpm 110/70 mmHg 110/60 mmHg

March 5, 2010 3pm-11pm Shift 4pm 8pm 38C 38.3C 89 bpm 92 bpm 23 cpm 22 cpm 100/70 100/60 mmHg mmHg

11pm-7am Shift 12am 4am 38.2C 38.2C 95 bpm 95 bpm 24 cpm 24 cpm 110/70 100/70 mmHg mmHg

PHYSICAL ASSESSMENT
GENERAL SURVEY:

Received patient lying on bed with an IVF (PLNSS 1L) attached at the right arm, awake and conscious. Patient facial expression reflects tardiness, he appeared weak and fatigue. During our assessment, he wears clean clothes.

SKIN:

Pectichial rash noted Warm to touch No skin lesion Normal skin turgor

Tourniquet Test (Rumpel Leads Test)

16

Inflate the blood pressure cuff on the upper arm to a point midway between the systolic and diastolic pressure for minutes Release 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. Or a test is (+) when 20 or more petechiae per 2.5 cm. square or 1 inch square are observed. Evenly distributed hair Short and thick hair Black color No dandruff on the scalp noted

HAIR:

NAILS:

Short, clean nails of both fingers and toes noted Nails are convex curvature with an angle at about 160 degrees No early clubbing noted Nail texture is smooth Tissue surrounding nails are intact

EYES AND VISION:

No edema or tenderness, over lacrimal gland PERRLA observed Symmetric in shape Coordinated eye noted/blink reflex intact No discharge noted No pain palpation Auricles same color as facial skin No difficulty in hearing spoken words Pinna recoils after it is folded Symmetric in shape

EARS AND HEARING:

NOSE AND SINUSES:

Colds noted No pain upon palpation Symmetrical and straight Uniform in color as facial skin

MOUTH, LIPS AND THROAT:

17

Slightly Pink lips noted Tongue in central position Teeth is yellowish in color Pink gums(bluish or dark patches in dark skin client)

NECK:

Trachea is central placement in the midline of the neck Muscles equal in size, head center Abdominal pain upon palpation Audible bowel sounds noted

GASTROINTESTINAL:

MUSCOLOSKELETAL:

No history of fracture Body weakness noted Muscle strength equal

CADIOVASCULAR AND PEIPHERAL SYSTEM:

Pulse:57 bpm Patient is not cyanotic No palpation noted No jugular vein

GENITOURINARY SYSTEM:

No pain noted With yellow urine noted

CRANIAL NERVES:
I. Olfactory- Able to identify different aromas
II. Optic- Patient has normal visual acquity III. Oculomotor- Pupil is constricted upon focusing in the light IV. Trochlear- Patient eyeball can able to move downward & laterally

V. Trigeminal:
a) Opthalmic branch- blink reflex present

b) Maxillary branch- able to fail sensation being introduced to him

c) Mandibular branch- able to clench his teeth

VI. Abducens- able to move his eyeball laterally of both eyes

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VII. Facialspontaneously

patient can able to identify various test, and can open his eyes

VIII. Auditory:
a) Vestibular branch- the patient is cooperative b) Cochlear branch- patient can hear clearly

IX. Glossopharyngeal- patient has no problem on swallowing X. Vagus- patient has no problem in swallowing XI. Accessory- patient has full range of motion and can turn head left and right side. XII. Hypoglossal- able to protrude his tongue and move it is side to sides.

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Cranial Nerve Assessment

Nerve
I II

Name
Olfactory Optic

Function
Smell Visual Acuity Visual Field

Test
Have athlete smell a familiar odor Have athlete identify fingers Check peripheral vision Shine Light in the eye Follow finger without moving the head Touch the face Have athlete hold mouth open Lateral Eye movements Smile, wrinkle face, puff cheeks Tastes Snap fingers by the ear Rhomberg's Test Swallow and say "AH"

III IV V

Oculomotor Troculear Trigeminal

Pupillary Reaction Eye Movement Facial Sensation Motor Function

VI VII

Abducens Facial

Motor Function Motor Function Sensory

VIII

Acoustic

Hearing Balance

IX

Glossopharyngeal

Swallowing and Voice Gag Reflex Neck Motion Tongue Movement and Strength

X XI XII

Vagus Spinal Accessory Hypoglossal

Use tongue depressor Shoulder shrugging Stick out tongue apply resistance with a tongue depressor

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Anatomy and Physiology

Blood Human blood smear: a erythrocytes; b neutrophil; c eosinophil; d lymphocyte.

Blood is a specialized bodily fluid that delivers necessary substances to the body's cells such as nutrients and oxygen and transports waste products away from those same cells. Blood is composed of:

Red cells or erythrocytes

Large microscopic cells without nuclei. Produced continuously in our bone marrow from stem cells at a rate of about 2-3 million cells per second. Make up 40-50% of the total blood volume. Transport oxygen from the lungs to all of the living tissues of the body and carry away carbon dioxide. Have about 270,000,000 iron-rich hemoglobin molecules. Red color of blood is primarily due to oxygenated red cells. Exist in variable numbers and types but make up a very small part of blood's volume--normally only about 1%. They occur elsewhere in the body as well, most notably in the spleen, liver, and lymph glands. Most are produced in our bone marrow from the same kind of stem cells that produce red blood cells. Others are produced in the thymus gland, which is at the base of the neck.

White cells or leukocytes

21

Some white cells (called lymphocytes) are the first responders for our immune system. Some white cells (called lymphocytes) are the first responders for our immune system.

Platelets or thrombocytes
cell fragments without nuclei that release blood clotting chemicals at the site of wounds. They do this by adhering to the walls of blood vessels, thereby plugging the rupture in the vascular wall. They also can release coagulating chemicals which cause clots to form in the blood that can plug up narrowed blood vessels. Individual platelets are about 1/3 the size of red cells. They have a lifespan of 9-10 days. produced in bone marrow from stem cells.

Hemoglobin

is the iron-containing oxygen-transport metalloprotein in the red blood cells of vertebrates,] and the tissues of some invertebrates. Hemoglobin has an oxygen binding capacity between 1.36 and 1.37 ml O2 per gram of hemoglobin,[2] which increases the total blood oxygen capacity seventyfold.

Plasma
Clear liquid water (92+%), sugar, fat, protein and salt solution which carries the red cells, white cells, platelets, and some other chemicals. Normally, 55% of our blood's volume is made up of plasma. About 95% of it consists of water. Contains blood clotting factors, sugars, lipids, vitamins, minerals, hormones, enzymes, antibodies and other proteins. It is likely that plasma contains some of every protein produced by the body--approximately 500 have been identified in human plasma so far.

Functions of Blood
22

Ex Th ces e s kid sal ne t is ys re filt mo er ve all d of Tr 1. fro the ans m blo po Di the od rts sso bo in : W lve dy the ast d in bo Ho e gas uri dy rm pro es ne, (ap En on du (e. wh pro zy es; cts g. Nu ich x. me of ox trie ma 8 s; me Pla yg nts y pin tab sm en, (su co ts), Bl oli a car ch nta 36 oo sm pro bo as in tim Maintains Body Temperature d 2. (e. tei n glu aro es cel g. ns dio cos un ev ls wa (as xid e, d ery Co Th (in ter, soc 3. e); am 10 24 ntr e cl. ure iat ino g ho pH ols wh a); ed aci sal urs of pH ite wit ds, t . blo blo Re h mi per To 4. od od mo def cro da xin mu cel ens ves y s st ls e, tox nut (su re 'le suc ins rie Re ch mo ma uc5. h fro nts as ve gul in oc as m (vi in d ati yte blo ta the fro on the s', odmi bo cas m ran of an clo ns es the dy ge Bo d ttin & of blo 6.8 dy red g mi pe od to Flu blo an ner opl by 7.4 od id d Constituent of Human Blood als e the , cel Ele ant ), on kid oth ls ctr ifatt we ne er 'er oly bo y ste ys wi yth tes die aci rn lea se roc s); Structure ds, die ve it yte gly ts the be s'). cer co bo gin ol) nta dy s ; ini in to ng the da mo uri ma re ne. ge sal cel t (T ls.

Functions

23

Plasma

Normal blood plasma is 90-92 % water. This is the straw-coloured fluid in which the blood cells are suspended, and consists of: Dissolved substances including electrolytes such as sodium, chlorine, potassiun, manganese, and calcium ions; Blood plasma proteins (albumin, globulin, fibrinogen); Hormones.

The medium in which the blood cells are transported around the body (by the blood vessels) and are able to operate effectively. Helps to maintain optimum body temperature throughout the organism. Helps to control the pH of the blood and the body tissues, maintaining this within a range at which the cells can thrive. Helps to maintain an ideal balance of electrolytes in the blood and tissues of the body.

Erythrocytes Immature erythrocytes have a nucleus but mature erythrocytes (Red blood have no nucleus. cells)
Haem Erythrocytes have a "prosthetic group" (meaning "in addition to" in this case, in addition to the cell). The active component of this prosthetic group is Haem. Haem relies on the presence of iron (Fe). Haem combines with oxygen to form oxyhaemoglobin:

Carry oxygen

. Erythrocytes are eventually broken down by the spleen into the blood

24

pigments bilinubin and bilviridin, and iron. These components are then transported by the blood to the liver where the iron is recycled for use by new erythrocytes, and the blood pigments form bile salts. (Bile breaks down fats.) Have a longevity of approx. 120 days. There are approx. 4.5 - 5.8 million erythrocytes per micro-litre of healthy blood (though there are variations between racial groups and men/women).

Leucocytes (White blood cells)

There are different types of leucocytes (described in more detail - below), classified as: Granular: e.g. Neutrophils, Eosinophils, Basophils. Agranular (do not contain granules): e.g. Monocytes, Lymphocytes. Have a longevity of a few hours to a few days (but some can remain for many years). There are approx. 5,000 - 10,000 leucocytes per micro-litre of blood.

Major part of the immune system.

Trombocytes Blood platelets are cell fragments; (Platelets)

Disk-shaped; Diameter 2-4 um (1 micro-metre = 1 um = 0.000001m);

To facilitate blood clotting - the purpose of which is to prevent loss of body fluids.

25

Have many granules but no nucleus; Have a longevity of approx. 5-9 days. There are approx. 150,000 400,000 platelets per micro-litre of blood.

The Oxygenation of Blood

The oxygenation of blood is the function of the erythrocytes (red blood cells) and takes place in the lungs. The sequence of events of the blood becoming oxygenated (in the lungs) then oxygenating the tissues (in the body) is as follows: The Right Ventricle (of the heart) sends de-oxygenated blood to the lungs. While in the lungs: 1. Carbon Dioxide diffuses out of the blood into the lungs, and 2. Oxygen (breathed into the lungs) combines with haemoglobin in the blood as it passes through the lung capillaries. Oxyhaemoglobin returns to the heart via the pulmonary vein and then enters the systemic circulation via the aorta. There is a low concentration of oxygen in the body tissues. They also contain waste products of the metabolism (such as carbon dioxide). Due to the high concentration of oxygen in the blood and the low concentration of oxygen in the tissues,

... the high concentration of carbon dioxide in the tissues diffuses into the blood. (95% of this carbon dioxide dissolves in the blood plasma.) Blood returns from the tissues back to the heart via the superior vena cava (from the upperbody) and the inferior vena cava (from the lower-body)

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REVIEW OF THE SYSTEM

INTEGUMENTARY SYST EM:

Patient has no history of skin disease No skin allergies in foods Skin is flush or pale pink rash all over the body Skin is slightly hot to touch during the 2nd assessment;

RESPIRATORY SYSTEM:

Patient has no difficulties in breathing No history of tonsillitis and sore throat

CARDIOVASCULAR SYSTEM:

No history of hypertension Pulse Rate is with in normal range Patient has no history of heart problem

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GENETOURINARY SYSTEM:

Patient urinates 4 times a day Patient has no history of renal disease

GASTROINTESTINAL SYSTEM:
Abdominal pain

MUSCULOSKELETAL SYSTEM:
Patient appeared weak and fatigue No history of any surgery

ENDOCRINE SYSTEM:

Patient has no history of thyroid problems

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NEUROLOGIC SYSTEM:

He is able to say what he feels and understand what his significant others say to him. No history of paralysis

HEMATOLOGIC:

Patients blood types is O antigen Hematocrit: as of March 3, 2010 is 41.7%; Mach 4, 2010 is 37 %, 37 % at 6:00pm, 34 %; March 5 , 2010 is 35% at 12 midnight. Platelet: as of March 3, 2010 is 55 x109/L; March 4, 2010 is 47 x109/L, 39 x109/L at 6:00 pm, 53 x109/L, March 5, 2010 at 12 midnight is 57 x109/L.

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LABORATORY RESULTS
HEMATOLOGY

March 3, 2010

TEST
Hematocrit Platelet count

RESULT
41.7 55

UNIT
% x109/L

REFERENCE
40-52 150-400

March 4, 2010

TEST
Hematocrit Platelet count

RESULT
37 47

UNIT
% x109/L

REFERENCE
40-52 150-400

March 4, 2010 6:00pm

TEST
Hematocrit Platelet count

RESULT
37 39

UNIT
% x109/L

REFERENCE
40-52 150-400

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March 4, 2010

TEST
Hematocrit Platelet count

RESULT
34 53

UNIT
% x109/L

REFERENCE
40-52 150-400

March 5, 2010- 12:00 midnight

TEST
Hematocrit Platelet count

RESULT
35 57

UNIT
% x109/L

REFERENCE
40-52 150-400

Urinalysis
Chemical reaction:

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TEST
Color Sugar Transparency Sp gravity Protein RBC E cells pH

RESULT
yellow negative clear 1.005 negative 0-1/hpf negative 6

REFERENCE
yellow- amber negative clear 1.010-1.030 negative 0-1 negative 6.5-7.5

SIGNIFICANC E
Normal Normal Normal Deluted Normal Normal Normal Acidic

Input and Output Monitoring Sheet

INTAKE
DATE ORAL PARENTERAL TOTAL DATE URINE

OUTPUT
STOOL OTHERS TOTAL

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7-3 3-11 11-7 80cc 80cc 700cc 450cc 1,310cc 780cc 530cc Total:

7-3 3-11 11-7 Total: 1800cc 900cc 900cc Total: 1800cc 900cc 900cc

INTAKE
DATE 7-3 3-11 11-7 ORAL 2000 cc 1500 cc 1000 cc PARENTERAL 400cc 300cc 150cc TOTAL 2400c c 1800c c 1050c c Total: 5,350cc DATE 7-3 3-11 11-7 URINE 1200c c 1000c c 900cc

OUTPUT
STOOL OTHERS TOTAL 1200c c 1 1 1000c c 900cc Total: 3,100c

Total: 3,100cc

DRUG STUDY
Date: March 3, 2010 (05:00pm) Generic Name: Aluminum Brand Name: Dosage: 20 cc now then 10 cc TID Classification:

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Indications: Mechanism of Action: Chemical Effect: Therapeutic Effect:

Contraindications:

ADVERSE REACTION:

Nursing Consideration:

Date: March 3, 2010 (06:00pm) Generic Name: Brand Name: Dosage: Classification: Salbutamol + guaifenesin

expectorant

Indications: Treatment for respiratory tract infection and for excessive mucus secretions

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Mechanism of Action: Reduces viscosity of tenacious secretions by increasing respiratory tract fluid

Contraindications: Contraindicated to patients with hypersensitive to the drug and its components

ADVERSE REACTION: CNS: dizziness, headache, insomnia, nervousness, tremor CV: hypertension, palpitations, tachycardia EENT: drying and irritation of nose and throat GI: heartburn, nausea, vomiting METABOLIC: hypokalemia, weight loss MUSCULOSKELETAL: muscle cramps

Nursing Consideration:

Date: March 3, 2010 (06:00pm) Generic Name: Brand Name: Dosage: Classification: Paracetamol Tempra 25mg/5ml 6 cc q 4 hrs prn nonopioid analgesic

Indications: Mild pain or fever. Mechanism of Action: Chemical Effect: May produce analgesic effect by blocking pain impulses, by inhibiting prostaglandin or pain receptor sensitizers. May relieve fever by acting in hypothalamic heat-regulating center. Therapeutic Effect: Relieves pain and reduces fever.

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Contraindications:

Contraindicated in patients hypersensitive to drug. Patient undergoing long term therapy for chronic non congestive angle-closure glaucoma, and patients with hyponatremia, hypokalemia, renal or hepatic impairment adrenal gland failure and hypercloremic acidosis.

ADVERSE REACTION: CNS: Drowsiness, Parathesia GU: Hematuria GI: Nausea Hematologic: Hemolytic anemia, neutropenia, leucopenia, pancytopenia, thrombocytopenia Hepatic: liver damage Metabolic: Hypoglycemia Nursing Consideration: Assess patients pain or temperature before and during therapy. Assess patients drug history. Many OTC products and combination prescription pain products contain acetaminophen. Calculate daily dosage accordingly. Be alert for adverse reaction and drug interactions. Date: March 3, 2010 ( 12 pm) Generic Name: Brand Name: Dosage: Classification: Ranitidine Zantac 35 mg IVTT q 8 hrs. Anti-ulcerative

Indications: Duodenal and gastric ulcer Gastroesophangeal reflux disease

Mechanism of Action: Chemical Effect: Competitively inhibits action if H2 at receptors sites of parietal cells, decreasing gastric acid secretion.

36

Contraindications: Contraindication in patients hypersensitive to the drug or any of its components.

Adverse Reaction: CNS: headache, fatigue CV: Chest pain GI: Nausea and vomiting, abdominal pain

Nursing Considerations: Assess patients GI condition before starting therapy and regularly there after to monitor the drugs effectiveness. Be alert for adverse reaction and drugs interactions. Assess patients and familys knowledge of drug therapy. Instruct patients not to drink alcohol during therapy. Date: March 3, 2010 Generic Name: Brand Name: Dosage: Classification: Ampicillin Novo-Ampicillin 500mg IVTT q 6hrs antibiotic

Indications: Respiratory tract or skin structure infection Gastrointestinal infection UTI Bacterial meningitis or septicemia

Mechanism of Action: Chemical Effect: inhibits cell-wall synthesis during microorganism multiplication. Therapeutic Effect: kills susceptible bacteria, including non-penicillinase producing Gram-positive bacteria and many gram-negative organisms. Contraindications:

37

Contraindicated in patients hypertensive to the drug or other penicillins. Adverse Reactions: CNS: seizure CV: vein irritation GI: nausea, vomiting, diarrhea, glossitis Hematologic: anemia, thrombocytopenia, leucopenia Other: anaphylaxis Nursing Consideration: Obtain history of patients infection before therapy and observe throughout therapy to assess improvement. Ask patient about previous allergic reaction to penicillin. A negative history of penicillin allergy doesnt rule out future reaction. Monitor patients hydration status if deserve GI reaction occurs.

PATHOPHYSIOLOGY
Precipitating Factors: Precipitating Factors: Age: 6 years old Sex: child Endemic area of Dengue Fever Infected mosquito Aedes aegypti Hanging clothes inside the house Rubber tires Empty cans

Bite of a Virus carrying Aedes aegypti mosquito Mosquito injects fluid into victims skin Virus enters blood stream Infects cells and generate cellular response

Fever Headache Abdominal pain Nausea Vomiting

Paracetamol
38

Ranitidine Ranitidine Ampicillin Dehydration

Initiates immune response (Stimulates release of cytokines)

Cytokines destroy cell membrane and cell wall

Develop non-neutralizing antibodies Increased activation of kinins and release vascular premeability

When treated early with doctor prescribe medications and manage to prevent the appearance of other symptoms IVFs and Electrolyte replacement and precautions

When illness becomes severe Damage cells due to both cytokines and virus

Convulsions

Hyperpyrexia Facial flushing

Petechial rash Increased capillary permeability

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Patient recovers

Thrombocytopenia Hemoconcentration Effusion Edema Low serum albumin

Circulatory collapse Decreased peripheral perfusion

Lowering of temperature Severe abdominal pain Bloddy vomitus Bleeding fom GIT in a form of melena Circulatory instability

NURSING CARE PLAN

No. 1 Date: March 3, 2010 Time: 7am-3pm shift ASSESSMENT:

Subjective cues: Tognaw ako lawas as stated by the client Objective cues: Flushed skin Warm to touch With pale and dry lips Irritability Noted Body Weakness Noted V/S monitoring Temp. 38.5, PR 88, RR 25, BP 110/70

DIAGNOSIS: Hyperthermia related to infection process secondary to dengue fever. PLANNING: Within 8 hours of rendering nursing intervention to our care patient &

significant others will be able to: Maintain core temperature within normal range, decrease of temperature from 38.5 C to normal. Demonstrate behavior to promote and maintain normothermia. Be free from any complication such as seizures or convulsion.

IMPLEMENTATIONS:

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Independent 1.Establish rapport 2.Close monitoring of V/S, 1&O 3.Perform TSB 4.Encourage to increase OFI 5.Provide cool environment 6.Promote adequate sleep and rest 7. Watch out for any signs & symptoms of complications or unusuality such as seizures. Dependent Nursing Intervention

Rationale To gain trust and cooperation To have a baseline data To facilitate heat loss by evaporation & conduction. To avoid dehydration To facilitate heat loss by conviction To decrease metabolic demands To be able to detect early signs and symptoms and provide appropriate nursing intervention

1. Administer PO meds. As ordered by the attending physician, paracetamol.

EVALUATION:

Goal met after the span of our care the patient & significant others was able to: Maintain core temperature with in normal range & decrease of temperature as evidence by 37.5 C temperature. Demonstrate behaviors to monitor & promote normothermia. Be free from any complications such as seizures and convulsion.

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No. 2 Date: March 3, 2010 Time: 7am-3pm shift ASSESSMENT:

Subjective cues: Sakit ako tiyan as verbalized by the patient. Objective cues: Grimace face noted With pale and dry lips noted Not in respiratory distress Irritability noted Restlessness noted Body weakness noted Pain scale of 6 over 10 Guarded position noted

DIAGNOSIS: Acute pain related to abdominal irritation secondary to dengue fever. PLANNING: Within 4 hours of rendering nursing intervention to our care patient &
significant others will be able to: Verbalize relieve of pain from pain scale of 6/10 t0 4/10 Follow prescribe pharmacological regiment & non pharmacological regiment Demonstrate use of diversion activity relaxation scales such as deep breathing exercise.

IMPLEMENTATIONS:
Independent 1. Establish rapport Rationale To gain trust & cooperation

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2. Assess for pain scale 3. Provide comfort measure & guide environment 4. Encourage use of relaxation technique such as deep breathing exercise 5. Encourage verbalization of feeling

To have a baseline data To promote non-pharmacological pain management To destruct attention & reduce tension To asses the intensity of pain

Dependent nursing Intervention Give medication as prescribe by the attending physician, Ranitidine.

EVALUATION:

Goal met after our nursing intervention, patient and significant others was able to: Verbalized relieve of pain as evidence by pain scale of 4/10. Follow prescribed pharmacological regiment and nonpharmacological. Demonstrate use of diversional activities or relaxation scale such as deep breathing exercise

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No. 3 Date: March 4, 2010 Time: 7am-3pm shift ASSESSMENT:

Subjective cues: dili ako katuyog kay dukag ako lawas as verbalized by the client Object cues:

Sunkin eyes noted Restlessness noted Irritability noted Body weakness noted Yawning noted

DIAGNOSIS: Sleep retardation related to prolong discomfort (itchiness & cough) secondary
to dengue fever.

PLANNING: Within 8 hours of rendering nursing intervention to our care patient and
significant others will be able to: Identify appropriate intervention to promote sleep Report in improvement in sleep pattern.

IMPLIMENTATIONS:
Independent 1. Establish rapport 2. Recommend quit activities such as listening to sopping music 3. Provide calm, quit environment & manage controllable sleep disrupting factors. 4. Encourage client to verbalize feeling regarding discomfort. 5. Encourage to increase OFI. Rationale To gain trust & cooperation To reduce stimulation to client to relax To assess client to establish optimal sleep pattern To assess its intensity To lessen or reduce coughing

44

Dependent Nursing Intervention Administer PO meds. As prescribe by the attending physician.

EVALUATION:

Goal partially met after the span of our care the patient and significant others was be able to:

Identify appropriate intervention to promote sleep. Report improvement in sleep pattern as evidence by patient verbalization of ok naman akong katolog

No. 4 Date: March 4, 2010 Time: 7am-3pm shift

45

ASSESSMENT:
Subjective cues: Kasokahon ako kay lood man gud as verbalized by the patient. Objective cues: Gagging noted Vomited 3x with a normal amount Frequent swallowing noted Body weakness noted Restlessness noted

DIAGNOSIS: Nausea related to pharmaceutical side effect secondary to dengue fever. PLANNING: Within the span our care the patient & significant others will be able to reduce:
Reduce & prevent the tendency to vomit Relieve & prevent the feeling of nausea Provide rest & comfort.

IMPLIMENTATIONS:
Independent 1. Establish rapport 2. Assess for the tendency to vomit 3. Provide clean peaceful environment 4. Provide frequent oral care 5. Encourage deep & slow breathing Rationale To gain trust and cooperation To be able to assess the frequency of nausea They maybe able to reduce the stimulation or worsen nausea To cleanse mouth & minimize bad taste To limit dwelling on unpleasant sensation

Dependent Nursing Intervention: Administration of PO meds as attending physician order, ranitidine.

EVALUATION:

Goal partially met after the span of our care patient & significant others was able to:

46

Reduce and prevent the Dengue to commit Relieve and prevent the feeling of nausea as evidence by watcher verbalization ni arang arang na cya, dli pareha adtong kagainah. Provide rest and comfort

No. 5 Date: March 4, 2010 Time: 7am-3pm shift

ASSESSMENT:

47

Subjective cues: Katol lage ako lawas as verbalized by the patient. Objective cues: With skin rushes noted Restlessness noted Irritability noted Not in respiratory distress Body weakness noted Frequent itching

DIAGNOSIS: Impaired skin integrity related to presence of rushes secondary to dengue fever

PLANNING: Within the span of our care patient & significant others will be able to:

Participate prevention measures & treatment program. Verbalize feelings & ability to manage situation.

IMPLIMENTATIONS:
Independent 1. Establish rapport 2. Encourage to verbalize skin discomfort 3. keep the area clean & dry 4. Provide comfort measures 5. Inspect skin rashes Rationale To gain trust and cooperation To assess the intensity To assess bodies natural process of repair To promote non-pharmacological managements To assess client with correcting or minimize the condition

EVALUATION:

Goal partially met after the span of our care the patient & significant others was able to:

Participate in prevention measures & treatment program. Verbalized feelings & ability to manage situation as evidence by patient verbalization of katol cja pero dili nako kayoton kay bac masamad cya.

48

No. 6 Date: March 5, 2010 Time: 7am-3pm shift

ASSESSMENT:
Objective cues: With pale & dry lips noted, restlessness noted. Body reflex noted Irritability noted Warm to touch V/S monitoring

49

DIAGNOSIS: Risk for deficient fluid volume related to excessive losses to normal route
secondary to dengue fever.

PLANNING: Within the span of our care the patient & significant others will be able to:
Identify risk factors appropriate intervention Illustrate behavior or lifestyle changes to prevent development of fluid deficit

IMPLIMENTATIONS:
Intervention 1. Establish rapport 2. Monitor IV 3. Evaluate nutritional status, noting current intake & problems 4. Monitor I & O balance 5. Weight client & compare 6. Encourage to increase OFI 7. Render health teaching regarding the importance of hydration Rationale To gain trust and cooperation To have a baseline data This can negatively effect fluid intake To insure accurate picture of fluid status To determine trends To promote hydration process For the proper understanding of the treatment or procedure treatment

EVALUATION:

Goal met after the span of our care the patient & significant others was able to:

Identify individual risk factors & appropriate intervention. Demonstrate behavior or lifestyle changes to prevent development of fluid volume deficient as evidence by painomon na nako ug daghan nga tubig as verbalized by the watcher.

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DISCHARGE PLAN
Upon the discharge from Caraga Regional Hospital, the patient as well as the significant others will be given a written home care instruction which contains the ff:

INDICATIONS ENVIRONMENTAL CONCERNS

Advise patient and significant others to keep all hanging clothes and always replace the water in the vase. Instruct patient and S.O to wear pajama and sweat shirt and to put on mosquito net when sleeping or apply off lotion. Screen the door, windows, and spray insect repellant. Encourage patient and S.O to clean their surrounding.

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TREATMENT
Encourage patient and S.O to take medications and vitamins daily as prescribed. Instruct patient to eat

HEALTH TEACHINGS
Advice patient to have enough rest and sleep. Instruct patient and S.O to conserve energy by balancing activities with rest periods. Teach S.O to take the medications on time as so to achieve the maximum therapeutic effect of drugs. Advise patient and S.O to have a healthy lifestyle. Advise the significant others to assist patient in coping with his illness.

OUT PATIENT (FOLLOW UP CHECK- UP)

Remind the SO of the patient to have follow-up check-up on the date scheduled by his physician, one week following his discharge. Advise the patient and remind the S.O to take rest upon his discharge and long exhausting travel going back to Cuyago, Jabonga, AND. Advised the S.O to seek medical help immediately the following: 1. 2. 3. 4. sudden blurring of vision sudden nausea and vomiting skin rashes dry lips

DIET

Teach patient and S.O how to become wise consumer by means of examining nutrition labels ( like). Advise patient and remind S.O to eat on more nutritious foods like green leafy vegetables, fruits, meat, and fish.

SPIRITUAL
52

Encourage patient and S.O to put his trust and faith in God alone. Teach patient and S.O to count his blessings and thank God despite the circumstances. Always remember and pray to God, ask guidance and guardian to guide in daily living.

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