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INTRODUCTION
Our client Mr. JM 8 years old, living in Norzagaray, Bulacan, was diagnosed with DHF II (Dengue Hemorrhagic Fever stage 2). His primary
complaints are abdominal pain, headache and fever. He is a grade three student and studying at FVR elementary school. His parents are Mrs. A 33 years
old and Mr. M 42 years old. Our patient was born in Korean because his parents are working on that country.
Dengue Fever is caused by one of the four closely related, but antigenically distinct, virus serotypes Dengue type 1, Dengue type 2, Dengue type 3,
and Dengue type 4 of the genus Flavivirus and Chikungunya virus. Infection with one of this serotype provides immunity to only that serotype of life, to a
person living in a Dengue-endemic area can have more than one Dengue infection during their lifetime. Dengue fever through the four different Dengue
serotypes are maintained in the cycle which involves humans and Aedes aegypti or Aedes albopictus mosquito through the transmission of the viruses to
humans by the bite of an infected mosquito. The mosquito becomes infected with the Dengue virus when it bites a person who has Dengue and after a week
it can transmit the virus while biting a healthy person. Dengue cannot be transmitted or directly spread from person to person. Aedes aegypti is the most
common aedes specie which is a domestic, day-biting mosquito that prefers to feed on humans.
.The biggest increase of Dengue cases in the country was seen in Metro Manila, where there was an almost 200 percent increase. According to
government figures 15,061 cases of the disease in the Philippines were reported in the first six months of the year. The increase in the number of dengue
cases may be attributed to the constantly changing climate brought by global warming as well as congestion in urban areas. Deaths due to dengue rose to 172
compared with 115 for the first half of 2007. Metro Manila had the highest number of cases, an increase of 191 percent over the same period in 2007.World
Health Organization officials earlier this year warned climate change was increasing the incidence of dengue fever and other infectious diseases in the
country. There is no known cure or vaccine for dengue fever, which is transmitted by the white-spotted mosquito. The Philippines Department of Health
(DOH) today reported that a total of 2,332 dengue cases has been admitted to sentinel hospitals nationwide from January 1 to May 15 this year. There were
sixteen deaths recorded. Partial reports from the DOH National Epidemiology Center (NEC) indicate a 58% decrease in the number of cases this year
compared with the same period last year. The NEC report also revealed that the regions with the highest number of cases were the National Capital region
(732 cases), Region 3 (307), Region 5 (268), and Region 7 (231). The ages of cases ranged from 1 month to 75 years old, with forty-six percent (535) of the
cases belonging to the 1-9 years age group.
OBJECTIVES:
Knowledge Objectives:
-
To know the effects of DHF to our patient and the right intervention specified for him.
To know the essentiality of the case that would assist us student-nurses to build a holistic knowledge, skills and attitude approach to learning .
Skill Objective:
1. Identify the risk factors that occur in the disease and make a pathophysiology about the disease.
2. Formulate significant diagnosis that is related to Nursing Care Plan and make a nursing care plan.
3. Identify the medications administered to the client and the drugs indication, contraindication, side effects, and nurses responsibility.
Attitude Objective:
1. To build trust and rapport to the patient.
2. To gain cooperation and trust from the patient.
3. To gain trust and cooperation from the relatives of the patient.
II.
NURSING ASSESSMENT
A. PERSONAL DATA
NAME: Mr. JM
AGE: 8 years old
SEX: Male
ADDRESS: Friendship Village Resour, Norzagaray Bulacan
MARITAL STATUS: Single
BIRTHDATE: February 16, 2002
NATIONALITY: Filipino
BIRTHPLACE: Korea
EDUCATIONAL ATTAINMENT: Grade 3 student
POSITION IN THE FAMILY: Son
RELIGION: Roman Catholic
HEALTH CARE FINANACING AND USUAL SOURCES OF MEDICAL CARE: Mother
DATE ADMISSION: September 6, 2010
TIME: 1:20 pm
B. CHIEF COMPLAINT
Mr. JM was admitted to Bulacan Medical Center with a chief complaint of abdominal pain and headache.
C. HISTORY OF THE PRESENT ILLNESS
The client experienced having abdominal pain every time his stomach is full. He was just lying on bed when the abdominal pain started. He was
brought by his mother to Roquero hospital because of having fever, abdominal pain and headache and after 2 days he was transferred to BMC because his
family observes having no improvement on their sons situation. He was given Ampicillin and Augmentin at the Roquero hospital. He was given Ranitidine
at the BMC hospital for treatment of the abdominal pain.
D. HISTORY OF THE PAST ILLNESS
The client doesnt have any allergies and havent encountered any accident or injuries. He has completed his immunization according to his aunt. It
was his second hospitalization because he was just transferred to BMC. He just had taken Paracetamol every time he experience having fever and headache.
3
HM
84 Y/O
HPN
OM
47 Y/O
KM
44 Y/O
MM
42 Y/O
YC
89 Y/O
KC
76 Y/O
AM
33 Y/O
AC
30 Y/O
MALE
FEMALE
PATIENT
DECEASED
ASTHMA
HPN Hypertension
JM
8 Y/O
Arthritis
The client is the only child of Mr. M.M and Mrs. A.M. He was born in Korea where his parents are working; when he was around 26 days old thats
the time he was brought here in the Philippines. It was the first incidence of having Dengue in their family. His grandfather has arthritis and hypertension
while his grandmother has asthma and the rest of the families are healthy.
AMOUNT
100 ml
FREQUENCY
4 times a day
Once a day
COLOR
Yellow
Brown
ODOR
Pungent
Foul
D. ACTIVITY-EXERCISE PATTERN
Mr. JM has sufficient energy for completing his desired activities, like during playing and doing activities at school. During his spare time he would
play outdoor activities with his neighbors.
0-Feeding
0-Dressing
IV- Home maintenance
0-Bathing
0-Grooming
II-Shopping
0-Toileting
0-General Mobility
0-Bed Mobility
IV-Cooking
K. VALUE-BELIEF PATTERN
The client is a catholic and they believe in God. For their family it is really important to have a connection to God. It really helps every time they are
facing a problem and during his stay in the hospital his family is praying for his wellness.
G. GROWTH AND DEVELOPMENT
PSYCHOSOCIAL
PSYCHOSEXUAL
COGNITIVE
MORAL
STAGE
School Age
Industry vs. Inferiority
DEFINITION
Conventional (Interpersonal
Concordance Orientation
Stage)
III.
Veins draining the upper portion of the body lead to the superior vena cava.
Veins draining the lower part of the body lead to the inferior vena cava.
BLOOD
Blood is a liquid tissue. Suspended in the watery plasma are seven types of cells and cell fragments.
platelets or thrombocytes
10
neutrophils
eosinophils
basophils
lymphocytes
monocytes
hormones
heat
11
Defense of the body against infections and other foreign materials. All the WBCs participate in these defenses
Are produced in the bone marrow (some 1011 of them each day in an adult human!).
are very rare (only about one in 10,000 bone marrow cells);
are attached (probably by adherens junctions) to osteoblasts lining the inner surface of bone cavities;
More stem cells (A mouse that has had all its blood stem cells killed by a lethal dose of radiation can be saved by the injection of a single
Cells that begin to differentiate along the paths leading to the various kinds of blood cells.
12
IV.
Non Modifiable
Factors;
-age
Modifiable Factors;
-environment
(sanitation)
WBC
13
14
PHYSICAL ASSESSMENT
Name: Mr. JM
Birthday: February 16, 2002
Age: 8 y/o
Date of Assessment: Sept. 08, 2010
Weight: 27 kg.
Height: 411
Parts to be Examined
1. GENERAL SURVEY
Body built, height & weight in
relation to clients age, lifestyle
and health
Vital signs:
Temperature: 38.4C
Pulse rate: 90 bpm
Respiratory rate: 35 cpm
Blood pressure: 100/70mmHg
BMI: 12.0
Technique
Normal Findings
Actual Findings
Inspection
Proportionate, varies
with lifestyle
He has a proportionate
body built which is
appropriate with his
lifestyle
He is slightly
unrelaxed and has
minimal movements
Inspection
Relaxed, erect
posture; coordinated
movement
Inspection
Clean, neat
Inspection
Body and breath odor
No body odor or
minor body odor
relative to work or
He dresses cleanly,
neatly and
appropriately.
He has no body &
breath odor.
Interpretation
Normal
Deviation from
Normal due to
discomfort and
illness.
Normal
Normal
15
Clinical Measurements
Height
Weight
exercise; no breath
odor
Underweight = <18.5
Inspection
Normal weight = 18.524.9
Inches 411
27 kg.
BMI =12.0
The client is
underweight
based on the
result of BMI.
Overweight = 25-29.9
Obesity = BMI of 30 or
greater
Vital Signs
Temperature
Pulse rate
Respiratory Rate
Blood Pressure
Inspection
Palpation
Inspection
Auscultation and
Palpation
36.5-37.5 C
60-100bpm
12-21cpm
120/80mmhg
38.4 C
90bpm
35cpm
100/70mmhg
BEHAVIOR
Signs of distress, in posture or
facial expression
Inspection
No distress noted
On stress
Inspection
Healthy appearance
Inspection
Cooperative, able to
follow instructions
Inspection
Appropriate to
situation
He has an unhealthy
appearance
He is very cooperative
and able to follow my
instructions
He responds
appropriately
Clients attitude
Clients affect/mood;
appropriateness of clients
response
Quantity of speech, quality
Understandable,
Temperature are
elevated due to
increased WBC
Deviation from
Normal due to
hospitalization.
Deviation from
Normal due to
illness.
Normal
Normal
He speech is slightly
16
Inspection
Inspection
Inspection
Presence of edema
Inspection
Inspection
Skin moisture
Inspection
understandable,clear
and has association of
thoughts
He has relevance of
thoughts that makes
sense and has a sense
of reality
Normal
Normal
Deviation from
Normal d/t
decreased tissue
perfusion &
peripheral
vasoconstriction.
Deviation from
normal d/t IV
infusion
Normal
Deviation from
Normal d/t
uncomfortable
environment.
17
Skin temperature
Palpation
Skin turgor
Palpation
B. NAILS
Fingernails shape, curvature and
angle
Inspection
Palpation
Inspection
Convex curvature;
angle of nail plate
about 160
No visible lines and
cracks Smooth texture
Highly vascular and
pink in light-skinned
people; dark-skinned
may have brown or
black pigmentation in
longitudinal streaks
Inspection
Intact epidermis
3. HEAD
A. SKULL
Size, shape and symmetry
Palpation
Inspection
Rounded
(normocephalic);
smooth skull contour
He has an intact
epidermis with no
hangnails
There is a prompt
return of blood
resulting to the usual
color, delayed for 4
sec.
His skull is rounded
and has a smooth skull
contour
Deviation from
normal due to
increase body
temperature
Deviation from
Normal d/t blood
circulation
Normal
Normal
Deviation from
Normal d/t poor
arterial
circulation.
Normal
Deviation from
Normal d/t poor
arterial
circulation.
Normal
18
B. EYELASHES
Evenness of distribution and
Palpation
Smooth, uniform
consistency; absence
of nodules and masses
Inspection
Normal
Evenly distributed
thick hair
Smooth texture; no
oiliness
Normal
Deviation from
normal due to
hospitalization.
Normal
He has asymmetrical
facial features which
has asymmetrical
movements
Deviation from
Normal d/t illness
and
hospitalization.
No edema
Normal
Palpation
Inspection
Palpation
Inspection
Black
Inspection
Symmetrical facial
features and
movements
Inspection
No edema
Normal
Normal
Inspection
Hair evenly
distributed and the
curl is outward
He has an evenly
distributed hair in her
eyebrow and they are
aligned with equal
movement
Normal
Inspection
Equally distributed;
Normal
19
direction of curl
C. EYELIDS
Surface characteristics, position in
relation to the cornea, ability to
blink and frequency of blinking
D. CONJUNCTIVA
Bulbar Conjunctiva for color,
texture and presence of lesions
G. IRIS
Shape and color
Inspection
Skin intact; no
discharge or
discoloration; Lids
closed symmetrically
approximately 15-20
involuntary blinks per
minute
He has a smooth
eyelids with no
discharge; lids closed
symmetrically and has
15-20 blinks per
minute
Normal
Inspection
Transparent
capillaries sometimes
evident
Normal
Inspection
His Bulbar
Conjunctiva is
transparent and has
some visible small
capillaries
He has shiny, smooth
and reddish palpebral
conjunctiva
Deviation from
Normal d/t blood
circulation.
Inspection
Normal
Inspection
Transparent, shiny
and smooth; the
details of iris are
visible
He has a transparent,
shiny and smooth
cornea
Normal
Inspection
Normal
20
H. PUPILS
Color, shape and symmetry of size
Inspection
Normal
I. VISUAL ACUITY
Near Vision
Inspection
Able to read
newsprints
Normal
Distant Vision
Inspection
Inspection
Illuminated pupils
constricts
Pupils also constricts
when looking at near
objects, dilate when
looking at far objects
and converge when
near object is moved
toward the nose
N/A
J. PUPILS
Light reaction and accommodation
Normal
Inspection and
palpation
No edema, tenderness
or tearing
Normal
Inspection
Both eyes
coordinated, move in
unison, with parallel
alignment
Normal
B. VISUAL FIELD
21
6. EARS
A. AURICLES
Color, symmetry of size and
position
Inspection
Normal
Inspection
Normal
Palpation
Inspection
Dry cerumen,
grayish-tan color,
sticky or wet cerumen
in various shades of
brown
He had no visible
cerumen, has a grayish
color
Normal
Inspection
Inspection
Webers test
Inspection
Rinne test
Inspection
Normal
Normal
Normal
Normal
Normal
22
conduction (Rinne
Positive)
7. NOSE
Deviations in shape, size or color
and flaring or discharge
Nasal cavities for presence of
redness, swelling, growths and
discharge
Nasal septum between the nasal
chambers
Patency of both nasal cavities
Inspection
Palpation
Symmetric and
straight; no discharge
or flaring; uniform
color
Mucosa pink; clear
watery discharge; no
lesions
Nasal septum intact
and in midline
Air moves freely as
the client breathes
through the nares
Not tender
Palpation
Not tender
Normal
Inspection
Deviation from
Normal d/t
illness.
Inspection
Normal
SINUSES
Tenderness
8. MOUTH
A. LIPS
Symmetry of contour, color and
texture
B. BUCCAL MUCOSA
Color, moisture, texture and
presence of lesions
Inspection
Positive)
Inspection
Inspection
Normal
There are no
tenderness, masses or
displacement of bones
and cartilage
Normal
Normal
Normal
Normal
23
C. TEETH
Color, number, condition and
presence of dentures
D. GUMS
Color and condition
E. TONGUE/ FLOOR OF MOUTH
Color and texture of the mouth and
frenulum
texture
Pre-schooler teeth;
smooth, white and
shiny tooth enamel
Inspection
Inspection
Normal
Deviation from
Normal d/t
decrease blood
circulation
Normal
Normal
Inspection
Inspection and
palpation
Palpation
Inspection
Inspection
Inspection
Normal
Deviation from
normal due to
bleeding
Normal
Normal
24
Inspection
Inspection
Inspection and
palpation
9. NECK
A. LYMPH NODES
Lymph Nodes and tenderness
B. TRACHEA
Placement
C. THYROID GLAND
Symmetry and visible masses
Smoothness, enlargement and
nodules
10. THORAX
A. POSTERIOR
Shape, symmetry, compare the
diameter of anteroposterior to
transverse diameter
Normal
Not palpable
Normal
Inspection and
palpation
Central placement in
midline of neck;
spaces are equal in
both sides
Normal
Inspection
Not visible on
inspection
Glands ascends
during swallowing;
painless, centrally
located and smooth
It is not visible
Normal
Normal
Normal
Palpation
Inspection
Chest symmetric;
anteroposterior to
transverse diameter in
ratio of 1:2
Spinal alignment
Inspection
Palpation
Spine vertically
aligned
Skin intact; uniform
temperature
Normal
Normal
Normal
25
Respiratory excursion
Inspection and
palpation
Vocal fremitus
Palpation
Percussion
Vocal fremitus
Auscultation
Inspection
Palpation
Inspection and
palpation
Palpation
temperature
He has a full and
symmetric expansion
and as she breathes,
thumbs usually
separate for 3-5 cm.
He has a bilateral
symmetry of vocal
fremitus; it is heard
clearly at the apex
His percussion notes
resonance sound
except over the
scapula and the lowest
resonance heard is at
the diaphragm
There are vesicular
and bronchovesicular
sounds heard
He has a quiet,
rhythmic and
effortless respiration
His skin is intact and
has uniform warm
temperature
He has a full and
symmetric expansion
and as he breathes,
thumbs usually
separate for 3-5 cm.
He has a bilateral
symmetry of vocal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
26
Percussion
Auscultation
Auscultation
11. CARDIOVASCULAR
Aortic and pulmonic areas
Tricuspid area
Apical area
Epigastric area
Auscultate aortic, pulmonic, apical,
tricuspid and epigastric area
Inspection and
palpation
Inspection and
palpation
Inspection and
palpation
Inspection and
palpation
Auscultation
Palpation
fremitus; it is heard
clearly at the apex
His percussion notes
resonance sound
except over the ribs
and the lowest
resonance heard is at
the diaphragm
There are bronchial or
tubular sounds heard
There are vesicular
and bronchovesicular
sounds heard
No pulsation
No pulsations felt
Normal
No pulsation; no lift
or heave
Some pulsations
visible; no lift or
heave
No pulsations or lift
and heave
There are some
pulsations felt but
there are no lift or
heave
There are aortic
pulsations
There are heart sounds
heard in all sites
Normal
Normal
Aortic pulsations
S1-usually heard at all
sites but louder at the
apical area
S2-usually heard at all
sites but louder at the
base of heart
Symmetric pulse
volumes; full
Normal
Normal
Normal
Normal
Normal
Normal
27
pulsations
Auscultate the carotid arteries
volumes and
pulsations
There are no sounds
heard
Auscultation
No sounds heard
Inspection
Normal
14. ABDOMEN
Skin integrity
Inspection
Unblemished skin,
uniform color
Flat, rounded or
scaphoid
No evidence of
enlarged liver and
spleen
Symmetric contour
He has unblemished
skin, uniform color
He has symmetric
contour
There are no evidence
of enlarged liver and
spleen
He has a symmetric
contour
He has symmetric
movements because of
respiration
There are no vascular
patterns seen
There are audible
bowel sounds heard
every 30 seconds but
no arterial bruits and
friction rub
There is tymphany
over stomach and gas
filled bowels
Normal
Abdominal contour
Inspection
Inspection
Symmetry of contour
Inspection
Abdominal movements
Inspection
Vascular patterns
Inspection
Auscultation
Percussion
Palpation
Symmetric
movements caused by
respiration
No visible vascular
patterns
Audible bowel sounds
usually occur every 520seconds; absence of
arterial bruits and
friction rub
Tympany over
stomach and gasfilled bowels; dullness
over the liver and
spleen or full bladder
No tenderness,
There is no tenderness,
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
28
Inspection
Inspection
Inspection
Palpation
Inspection and
Palpation
No contractures
No tremors
Normally firm
Smooth coordinated
movements
B. BONES
Normal structure and deformities
Edema and tenderness
Inspection
Palpation
No deformities
No tenderness or
swelling
He has no deformities
He has no edema,
tenderness and
swelling
Normal
Normal
C. JOINTS
Swelling
Inspection
No swelling
Positive swelling
Deviation from
Normal d/t
uncomfortable
environment.
Palpation
No swelling,
tenderness, crepitation
or nodules
There are no
tenderness, swelling,
crepitation or nodules;
Normal
15. MUSCULOSKELETAL
A. MUSCLES
Size, comparison on one side to
other side
Contractures
Fasciculation and tremors
Muscle tonicity
Muscle strength
Tenderness, smoothness of
movements, crepitation and
nodules
Normal
Normal
Normal
Normal
Deviation from
Normal d/t
illness.
29
Inspection
Normal
Date
Ordered
`Indication or Purpose
Sept.
07, 2010
The
CBC
provides
valuable information about
the blood and to some
extent the bone marrow,
which is the blood-forming
tissue. The CBC is used for
the following purposes:
as a preoperative test to
ensure both adequate
oxygen
carrying
capacity and hemostasis
to identify persons who
may have an infection
to diagnose anemia
to identify acute and
chronic illness, bleeding
tendencies, and white
blood cell disorders such
Result
Components
WBC
RBC
HGB
HCT
PLT
PCT
MCV
MCH
MCHC
RDW
MPJ
PDW
%Lymphocytes
#Lymphocytes
%Monocytes
#Monocytes
Actual Findings
2.2 L 109/L
6.20 H 1012/L
100 g/L
0.330
69 L 109/L
0.046 L 10-2/L
72 L fl
25.5 L pg
356 H g/L
16.7 H%
6.6 fl
10.1 %
39.3 %
0.8 L 109 L
13.3 H%
0.2 L 109L
Normal Values
Normal Findings
3.5 10.0
3.80 5.80
110 165
0.350 0.500
150 390
0.100 0.500
80 97
26.5 33.5
315 350
10.0 15.0
6.5 11.0
10.0 18.0
17.0-48
1.2-3.2
4.0-10.0
0.3-0.8
Nursing
Responsibilities
Before:
-Identify the
patient
-explain the
procedure to the
patient
-Inform the
patient that there
are no foods,
fluids, or
medications
restrictions,
unless by
medical
directions.
During:
-Instruct the
patient to
30
as leukemia
to monitor treatment for
anemia and other blood
diseases
To determine the effects
of chemotherapy and
radiation therapy on
blood cell production.
V.
%Granulocytes
#Granulocytes
47.4 %
1.2 L 109L
43.0-76.0
1.2-6.8
cooperate fully
and to follow
directions
during the
laboratory
procedures.
After:
-Secure the
laboratory
results of the
patient.
Normal
Normal
MEDICAL
MANAGEMENT
D5 0.3 NaCl
500 cc @
25 gtts/ min
DATE
ORDERED,
DATE RESULT
IN
GENERAL
DESCRIPTION
INDICATION/
PURPOSES
CLIENTS
RESPONSE
NURSING
RESPONSIBILITIES
31
Normal Saline
Solution
250 cc as fast
Drip
September 06,
2010
77 mEq/L solution
and 77 mEq/L
chloride.
of nutrient solution,
electrolyte solution,
alkalyzing solution &
acidifying solution.
Solution of
common salt in
distilled water, of a
strength of 0.9 per
cent. It is called
normal saline
because the
percentage of salt
resembles that of
the crystalloids in
the blood plasma.
Applied to a
wound an isotonic
causes no increase
in the flow of
lymph from the
capillary blood
vessels.
32
b. Drugs
Generic/ Brand
name
Ranitidine
Hydrochloride
(Zantac, Gavilast,
Aporanitidine.Ranitil
Ulzan)
Route of
administration,
dosage, frequency
250mg TIV q 8
General action,
classification,
mechanism of
action
Histamine-receptor
antagonist
Anti ulcer drug
Reduces gastric
secretion and
increases gastric
mucus and
bicarbonate
production, creating
a protective coating
in gastric mucosa.
Indication/
purposes
Treatment of
active duodenal
ulcer; maintenance
therapy for duodenal
ulcer patient after
healing of acute
ulcer; treatment of
gastro esophageal
Reflux disease:
short-term treatment
of active, benign
gastric ulcer;
treatment of
pathologic GI
hypersecretory
conditions (e.g.,
Zollinger-Ellison
syndrome, systemic
mastocytosis, and
postoperative
hypersecretion);
heartburn.
Clients response
No signs of any
adverse reaction.
Nursing
responsibilities
(Prior, during,
after)
Assess vital signs.
Monitor CBC and
liver function tests.
Assess patient for
epigastric or
abdominal pain and
frank or occult blood
in the stool, emesis,
or gastric aspirate.
Inform patient that
it may cause
drowsiness or
dizziness.
Inform patient that
increased fluid and
fiber intake may
minimize
constipation.
Advise patient to
report onset of black,
tarry stools; fever,
sore throat; diarrhea;
dizziness; rash;
confusion; or
hallucinations to
health care
professional
33
promptly.
c. Diet
Type of diet
September 6, 2010
General description
A human being
pattern of
eating.
It simply means
"eat anything
you want
except dark
colored foods.
Indications/Purposes
34
d. ACTIVITY/ EXERCISE
TYPE OF EXERCISE
DATE ORDERED/
DATE STARTED/
DATE
DISCONTINUED
GENERAL
DESCRIPTION
INDICATIONS/
PURPOSES
CLIENTS
RESPONSE TO
ACTIVITY
NURSING
RESPONSIBILITIES
September 6, 2010
important for
maintaining physical
fitness and can
contribute positively
to maintaining a
healthy weight,
building and
maintaining healthy
bone density, muscle
strength, and joint
mobility, promoting
physiological wellbeing, reducing
surgical risks, and
strengthening the
immune system.
- increasing
cardiovascular
endurance.
35
CUES
Subjective:
Nahihilo,
nanghihina at
sumasakit ang tiyan
ko as verbalized by
the patient.
Objective:
Pallor
Hemoglobin =
100 g/L
Hematocrit =
0.330 L/L
NURSING
DIAGNOSIS
SCIENTIFIC
KNOWLEDGE
Ineffective Tissue
Perfusion r/t
Decreased
hemoglobin
concentration in
blood AEB low
hemoglobin
concentration, pallor
and dizziness, and
muscle weakness.
Definition:
Decrease in oxygen
resulting in the
failure to nourish
the tissues at the
capillary level
[Tissue perfusion
problems can exist
without decreased
Viral infection
Decreased level of
hemoglobin and
hematocrit
Decreased blood
oxygenation
GOALS/
OBJECTIVES
NURSING
INTERVENTION
After 12 hours of 1.
nursing intervention,2. 1. a.) Encourage
the client will be
patient to take
able to:
iron
supplements and
1. Demonstrate
eat foods rich in
different ways to
iron.
improve blood
b.) Elevate head of
oxygenation and
bed to about 10
circulation.
degrees.
2. Verbalize
understanding of
condition and
importance of
treatment
regimen.
3. Demonstrate
increased tissue
perfusion.
RATIONALE
c.) Discourage
strenuous
activities.
2. a.) Provide health
teaching
regarding DHF
and Typhoid
Ilietis
b.) Provide health
teaching on
drugs being
EVALUATION/
EXPECTED
OUTCOME
1. a.)To help
After 32 hours of
elevate
nursing intervention
hemoglobin and the client was:
hematocrit levels
1. Demonstrated
different ways to
improve blood
b.) To promote
oxygenation and
circulation and
circulation.
venous drainage.
2. Verbalized
c.)To avoid
understanding of
increased oxygen
condition and
demand.
importance of
treatment
2. a.) To help client
regimen.
understand his
health condition.
b.)To maintain
compliance to
meds.
3. Demonstrated
increased tissue
perfusion
36
cardiac output;
however there may
be a relationship
between cardiac
output and tissue
perfusion.]
taken.
pallor, dizziness,
muscle weakness
Ineffective tissue
perfusion
Source:
Nurses Pocket
Guide Ninth Edition
3.
a.) Monitor vital
signs
.
b.) Encourage early
ambulation
when possible.
3.
a.)Serve as
basis for any
alteration in
system functions.
b.) Enhances
venous return.
Collaborative:
Administer
medications as
ordered
Administer and
regulate IVF as
ordered
Administer packed
RBCs
Monitor lab studies
( Hb,Hct, RBC count)
Help
control/alleviate
symptoms
Maintain
hydration and help
wash away toxins
Packed RBCs are
adequate for stable
patients with
subacute/chronic
bleeding to
increase oxygen
carrying
37
capability.
Aids in
establishing blood
replacement needs
& monitoring
effectiveness of
therapy.
Source:
Nurses Pocket Guide
Ninth Edition
Source:
Nurses Pocket
Guide Ninth Edition
CUES
NURSING
DIAGNOSIS
SCIENTIFIC KNOWLEDGE
GOALS/
OBJECTIVES
NURSING
RATIONALE
INTERVENTION
EVALUATION/
EXPECTED
OUTCOME
Hyperthermia
related to
inflammatory
response as
manifested by
body temperature
of 38.6 degree
Monocytes
Pyrogenic cytokines
After 4 hrs. Of
nursing
interventions,
the patient will
maintain core
temperature
within normal
Independent:
Rendered tepid
sponge bath
To promote
cooling surface
Encouraged to
increase fluid intake
To replace fluid
loss due to body
heat
Promoted surface
Heat is loss by
After 4 hrs. Of
nursing
interventions, the
patient was able
maintain core
temperature within
normal range.
38
the patient.
Objective:
Flushed skin,
warm to
touch.
Celsius, flushed
and warm to touch
skin.
Anterior hypothalamus
Increased Heat
Restlessness
Goal met.
cooling, loosen
clothing, and cool
environment
evaporation and
conduction
Encouraged
to have
adequate
bed rest
To reduce
metabolic
demands
Dependent:
V/S taken as
follows:
T: 38.6 C
P: 78
R: 19
BP: 110/80
range.
conservation(Vasoconstriction/behaviour
changes) Increased Heat production
(involuntary muscular contractions)
F EVER
Administered
Paracetamol
as ordered
To decrease
temperature
Administered IVF
as ordered
To support
circulating
volume and
tissue
perfusion
39
CUES
Subjective:
Palagi akong
nauuhaw, as
verbalized by the
patient
Objective:
> Decreased platelet
count= 69L
>Thirst
>Weakness
NURSING
DIAGNOSIS
Diagnosis:
Risk for deficient
fluid volume related
to decreased blood
volume secondary to
altered platelet
production
Definition:
The state in which an
individual is at risk
of experiencing
vascular, cellular, or
intracellular
dehydration
SCIENTIFIC
KNOWLEDGE
Recognition of
dengue viral antigen
on infected
monocyte by
cytotoxic cells
Cellular direct
destruction
Immunological
platelet survival
Platelet lyses
Hemorrhage
PLANNING
Short Term:
After 1 hr. of nursing
interventions, the
client will be able to
demonstrate
behaviors that reduce
the risk of decreased
fluid volume as
manifested by:
>
Increased oral
fluid intake.
>
Enumerate ways
to prevent
bleeding
NURSING
INTERVENTION
Independent:
> Note possible
conditions like
fluid loss and
limited intake.
>
Monitor I&O
RATIONALE
>These conditions
may lead to fluid
deficits
>To ensure
accurate picture of
fluid status
> Monitor VS
changes.
>Su-acute
disseminated
intravascular
coagulation may
develop seondary to
EVALUATION
Short term:
Goal Met.
After 1 hour of
nursing
interventions, the
client was able to
demonstrate
behaviors that reduce
the risk of decreased
fluid volume.
.> Increased oral
fluid intake.
> Enumerate ways
to prevent
bleeding
40
more sites.
altered clotting
factor
>Minimal trauma
can cause mucosal
bleeding
>Aids in establishing
blood replacement
needs & monitoring
effectiveness of
therapy.
Collaborative:
> Provide/ assist in >To replenish fluid
volume for severe
giving
dehydration
supplemental
fluids as indicated
(e.g. parenteral,
41
enteral)
VI.
DISHARGE PLANNING
METHODS
MEDICATION:
Continue taking prescribe medication for the patient on exact dosage, time, and frequency making sure that the purpose of the medication is truly discussed
by the health care provider.
Advice the significant others not to leave the patient during meds.
Advice the patient not to stop intake of prescribed meds, unless approved by the physician.
Dont give aspirin and NSAIDs, they increase the risk of bleeding. Any medicines that decrease platelet count should be avoided.
EXERCISE:
Instruct to avoid excessive activities that may result to stress. Just advised to perform range of motions and repetitive body movements for promotion of
optimum health. Remind about the need for health promotion activities such as reading, watching T.V, etc.
TREATMENT:
42
Instruct to drink plenty of water or fluids that are available at home and eat nutritious diet.
Advised to look for re-occurrence of danger signs and symptoms and report immediately.
HYGIENE:
OPD:
Instruct the family members to have a check-up or to consult physician once a while to monitor patients condition and for detection of recurrences and other
complications that may arise on to it.
DIET:
Instruct the family members to give the client protein rich foods such as meat, fish, eggs and dairy products.
VII.
CONCLUSION
As part of our requirement, we had learned so much in handling our client who DHF. We attained and follow certain standards and rules to promote
nurse patient interaction. With this case study, we gain knowledge that we can surely use in the future ahead. All we do to our client is the summary of what
we have learned in lectures in school. We also share some information with our client like the main probable cause and the risk factors of having DHF. We
do manage our time to give sufficient care to our beloved client. We believed that client is our work and we have the responsibility to attend to their needs
43
and serve them as best as we can. We are able to provide health teaching about the proper health care to our client with DHF. We started having an interview
by building trust to our client because at first, he wasnt like to share some information to us. But, as time goes by, we were able to let our client share some
information that will be very useful in this case studies.
VIII. BIBLIOGRAPHY
Schull, Dwyer Patricia, Nursing Spectrum DRUG Handbook, The McGraw-Hill Companies, Inc. copyright 2008
Wilkinson, Judith M, and Nancy R. Ahern, Nursing Diagnosis Handbook 9th edition, Pearson Education South Asia Pte. Ltd copyright 2009
Kozier, Barbara; Avory Berman; Glenora Erb and Shirlee Snyder, Fundamentals of Nursing 7th Edition, Pearson Education South Asia Pte. Ltd. Copyright
2004
Colbert, Bruce J; Jeff Ankney and Karen T. Lee, Principles of Anatomy & Physiology, an interactive journey, Pearson Education South Asia Pte. Ltd.
Copyright 2007
Walker, Richard Guide to the HUMAN BODY, Octopus Publishing Group Ltd. Copyright 2003
Delaune, Sue E. and Patricia K. Ladner, Fundamentals of Nursing, Standards and practice, 3rd edition, Thomson learning Asia,Copyright 2006
Nursing 2006 Drug handbook 26th edition, Lippincott Williams and wilkins
Deglin, Judith Hopper and April Hazard Vallerand, Daviss Drug Guide for Nurses, 9th edition
Nurses Pocket Guide: Nursing diagnoses with interventions 4th edition
Brunner & Suddarths, Medical and Surgical Nursing 10th edition, Lippincott Williams & Wilkins Copyright 1996
44