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Liceo de Cagayan University

RNP Blvd. Carmen, Cagayan de Oro City

College of Nursing

In partial fulfillment of
NCM501204
Related Learning Experience

Individual Case Study

Submitted by:

MEDEL, Roin Carl B.

Submitted to:

Gemma Reambonanza RN

Date:

Monday, July 26, 2010

TABLE OF CONTENTS

• Introduction
• Overview of the case
• Objective of the study
• Scope and Limitation of the study

• Health History
• Profile of patient
• Family and Personal Health history
• History of Present Illness
• Chief Complaint

• Developmental Data
• Medical Management
• Laboratory Results
• Drug Study

• Pathophysiology with Anatomy and Physiology

• Nursing Assessment (System Review & Nursing Assessment II)
• Nursing Management
• Ideal Nursing Management (NCP)
• Actual Nursing Management (SOAPIE)

• Referrals and Follow-up

• Evaluation and Implications
• Bibliography
I. INTRODUCTION
In every duty it is important for us nursing students to have a knowledge on the health problem
of our patients and know its nursing intervention that can help the patient to recover from their disease.
Before going to duty, the primary goal of a student nurse is to have a further assessment to be able to
come up to right nursing interventions. During our duty at Sabal Hospital we are able to encounter
certain health problems that lead us to choose for our own individual case study. Through this case
study, we are able to enhance our nursing knowledge and skills for us to be able to be competent
enough as we go on to our future duties. One of the health problems that made me interested is about
the case of my patient which is Dengue Fever.

A. Overview of the Case

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 these 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.
Dengue viruses are transmitted to humans through the infective bites of female Aedes
mosquito. Mosquitoes generally acquire virus while feeding on the blood of an infected person. After
virus incubation of 8-10 days, an infected mosquito is capable, during probing and blood feeding of
transmitting the virus to susceptible individuals for the rest of its life. Infected female mosquitoes may
also transmit the virus to their offspring by transovarial (via the eggs) transmission.

Humans are the main amplifying host of the virus. The virus circulates in the blood of
infected humans for two to seven days, at approximately the same time as they have fever. Aedes
mosquito may have acquired the virus when they fed on an individual during this period. Dengue
cannot be transmitted through person to person mode.
B. Objective of the Study

Individual care study provides goals or objectives which is necessary to serve as an

instrument in comprehensively assessing the patient’s health status and present condition. It also

focuses on the following aims:

• To conduct a thorough assessment of the patient in order to formulate appropriate nursing care
plan based on accurate and complete data;
• To formulate nursing diagnosis, develop outcomes and plan nursing care with specific goals for
a patient with Dengue Fever.
• To implement nursing care and evaluate outcomes for effectiveness and achievement of care;
and
• Integrate knowledge about Dengue Fever to achieve quality of care to the patient and

understand the course and essence of the chosen care study.

• Utilizing the nursing process in the management of patient’s health condition and in giving

quality nursing care.

• Obtain a complete health data that can be used in the follow-up care.

• Impart health teachings about necessary information pertaining to the disease condition.

• Add up additional knowledge and understanding in the Nursing profession.

C. Scope and Limitation of the Study

The extent of study includes the overall data gathered during the interview and observation as

manifested by the patient and his complaints. It also deals with the several factors observed during the

assessment within the span of time given. The information gathered was based on the manifestations

and complaints of the patient observed and the exact answers of the patient’s support person since the

patient is only 5 years old .Interventions were rendered gradually depending on the objective
assessment of the student. The following information only involves the exact words and answers

supported by the mother.

The limitation of the study includes the place of interaction itself which was in Sabal Hospital,

Station 3. The study was completed altogether by both research and actual hands-on exposure and

interaction with the patient's mother during the three (3) days clinical duty.

II. HEALTH HISTORY

A. Profile of the Patient

Name: Rafael M. Tuto

Age: 5 years old

Sex: Male

Birth date: September 20, 2005

Religion: Roman Catholic

Civil Status: Child

Nationality: Filipino

Occupation: None

Address: Brgy. 25 Cagayan de Oro City

Name of Father: Alfredo B. Tuto

Occupation: Security Guard

Name of Mother: Ephy M. Tuto

Occupation: Housewife

Date of Admission: July 7, 2010

Time of Admission: 10:20 am

Admitting Physician: Dr. J. Neri

Vital Signs Assessment

Temperature: 38.6 oC

Pulse Rate: 132bpm

Respiratory Rate: 28 cpm

Height: not obtained

Weight: Not obtained

Allergy: No known allergy

B. Family History and Personal Health History

Rafael’s father is a security guard while her mother is a plain housewife. They live in Brgy
25 Cagayan de Oro City. His father’s salary is enough for their living which has a net income of P10,
000.00/month. As I have interviewed her mother, the family has no known food and drug allergy. They
do not also have a family history of Diabetes and asthma.

C. History of Present Illness

• A case of 5 years old patient (male) from Brgy 25; with chief complaint of fever with epigastric

pain. Condition noted 2 days PTA on moderate grade fever (+) vomiting once. PTA (+)

epigastric pain. Prompted for admission.

D. Chief Complaint

Rafael M. Tuto , 5 years old, male, from Brgy 25 C.D.O was admitted to Sabal Hospital

due to fever with epigastric pain.

 Diagnostic Examination

Urinalysis

45rffff Name: Reuben Gabriel Dagoldol

dhhd Ward: Pediatric ward Date: 12/8/09
Trtgg Result Nursing interpretation
Color: yellow •Normal color of urine
Transparency:
Glucose -
Pus: 1-3 hpf
RBC: 1-3 hpf
Epithelial cells: few
Mucus thread: -
Bacteria: few •presence of bacteria
Ph: 6.0
SpGr: 1.080 •abnormal result of urine gravity
Complete Blood Count

Result Expected Values: Nursing Interpretation

WBC: 3,500 5,000 - 10,000/ mm3 Overwhelming infection

RBC: 4.28 4.35 - 5.90 mil/mm3 anemia
Hemoglobin: 11.6 g/dl 13.7 - 16.7 g/dl Risk anemia
Hematocrit: 34.9 vols % 40.5 - 49.7 vols % Anemia, malnutrition
Platelet Count: 190,000 144,000 – 372,000 low platelet count
Differential Count
Granulocyte: 40 43.4 – 76.2%
 Lymphocytes: 10.6 17.4% - 48.2% Viral infection
Monocytes: 7.8 0 -10%
Eosonophil: 08 0 – 6%

B. DRUG STUDY
Generic Name of ordered Maalox Syrup
drug
Brand Name Maalox Syrup
Date Ordered July 7, 2010
Classification Antacid
Dose/Frequency/Route 5 ml 3x daily PO
Mechanism of Action Slows intestinal motility by acting on the nerve endings on and or intramural ganglia
embedded in the intestinal wall
Specific Indication For treatment of stomach pain
Contraindication Discontinue if abdominal distention develops in ulcerative colitis in clients with
constipation
Side Effects/Toxic Effects Abnormal pain , distention, discomfort, dry mouth.
Nursing Precaution Hypersensitivity to drug. Discontinue after 48 hours and report if ineffective.

Generic Name of ordered drug Paracetamol

Brand Name
Date Ordered
Classification
Dose/Frequency/Route
Mechanism of Action
Specific Indication
Contraindication
Side Effects/Toxic Effects
Nursing Precaution
None
July 7, 2010
Non-opioid analgesic;antipyretic
5 ml q 4 hours PO PRN for signs of fever
Produces analgesic effect by blocking pain impulses, by inhibiting prostaglandins or
pain receptors sensitizers; may relieve fever by acting in hypothalamic heat
regulating center
For mild pain and fever
To patient’s going long-term therapy for chronic noncongestive angle-closure
glaucoma; hyponatremia; hypokalemia; hepatic impairment; adrenal gland failure’
hypechloremic acidosis
Confusion; anorexia; aplastic anemia; rash; renal calculi
Report signs of F/E imbalance
V. PATHOPHYSIOLOGY with ANATOMY AND PHYSIOLOGY

BLOOD

Blood is considered the essence of life because the uncontrolled loss of it can result to
death. Blood is a type of connective tissue, consisting of cells and cell fragments surrounded by a liquid
matrix which circulates through the heart and blood vessels. The cells and cell fragments are formed
elements and the liquid is plasma. Blood makes about 8% of total weight of the body.

Functions of Blood:
>transports gases, nutrients, waste products, and hormones
>involve in regulation of homeostasis and the maintenance of PH, body temperature, fluid balance, and
electrolyte levels
>protects against diseases and blood loss

PLASMA

Plasma is a pale yellow fluid that accounts for over half of the total blood volume. It
consists of 92% water and 8% suspended or dissolved substances such as proteins, ions, nutrients,
gases, waste products, and regulatory substances.

Plasma volume remains relatively constant. Normally, water intake through the GIT closely
matches water loss through the kidneys, lungs, GIT and skin. The suspended and dissolved substances
come from the liver, kidneys, intestines, endocrine glands, and immune tissues as spleen.

FORMED ELEMENTS

Cell Type Description Function

Erythrocytes (RBC) Biconcave disk, no nucleus, 7-8 Transport oxygen and carbon
micrometers in diameter dioxide
Leukocytes (WBC):

Neutrophil Spherical cell, nucleus with two Phagocytizes microorganism

or more lobes connected by thin
filaments, cytoplasmic granules
stain a light pink or reddish
purple, 12-15 micrometers in
diameter
 Basophil Spherical cell, nucleus, with
two indistinct lobes,
cytoplasmic granules stain blue-
purple, 10-12 micrometers in
diameter
Releases histamine, which
promotes inflammation, and
heparin which prevents clot
formation

Eosinophil Spherical cell, nucleus often Releases chemical that reduce

bilobed, cytoplasmic granules inflammation, attacks certain
satin orange-red or bright red, worm parasites
10-12 micrometers in diameter

Lymphocyte Spherical cell with round Produces antibodies and other

nucleus, cytoplasm forms a thin
ring around the nucleus, 6-8
micrometers in diameter
chemicals responsible for
destroying microorganisms,
responsible for allergic
reactions, graft rejection, tumor
control, and regulation of the
immune system

Monocyte Spherical or irregular cell, Phagocytic cell in the blood

nucleus round or kidney or
horse-shoe shaped, contain
more cytoplasm than
lymphocyte, 10-15 micrometers
in diameter
Platelet Cell fragments surrounded by a
cell membrane and containing
granules, 2-5 micrometers in
diameter
leaves the circulatory system
and becomes a macrophage
which phagocytises bacteria,
dead cells, cell fragments, and
debris within tissues
Forms platelet plugs, release
chemicals necessary for blood
clotting

PREVENTING BLOOD LOSS

When a blood vessel is damaged, blood can leak into other tissues and interfere with the
normal tissue function or blood can be lost from the body. Small amounts of blood from the body can
be tolerated but new blood must be produced to replace the loss blood. If large amounts of blood are
lost, death can occur.

BLOOD CLOTTING

Platelet plugs alone are not sufficient to close large tears or cults in blood vessels. When a
blood vessel is severely damaged, blood clotting or coagulation results in the formation of a clot. A clot
is a network of threadlike protein fibers called fibrin, which traps blood cells, platelets and fluids.
 The formation of a blood clot depends on a number of proteins found within plasma called
clotting factors. Normally the clotting factors are inactive and do not cause clotting. Following injury
however, the clotting factors are activated to produce a clot. This is a complex process involving
chemical reactions, but it can be summarized in 3 main stages; the chemical reactions can be stated in
two ways: just as with platelets, the contact of inactive clotting factors with exposed connective tissue
can result in their activation. Chemicals released from injured tissues can also cause activation of
clotting factors. After the initial clotting factors are activated, they in turn activate other clotting
factors. A series of reactions results in which each clotting factor activates the next clotting factor in the
series until the clotting factor prothrombin activator is formed. Prothrombin activator acts on an
inactive clotting factor called prothrombin. Prothrombin is converted to its active form called thrombin.
Thrombin converts the inactive clotting factor fibrinogen into its active form, fibrin. The fibrin threads
form a network which traps blood cells and platelets and forms the clots.

CONTROL OF CLOT FORMATION

Without control, clotting would spread from the point of its initiation throughout the entire
circulatory system. To prevent unwanted clotting, the blood contains several anticoagulants which
prevent clotting factors from forming clots. Normally there are enough anticoagulants in the blood to
prevent clot formation. At the injury site, however, the stimulation for activating clotting factors is very
strong. So many clotting factors are activated that the anticoagulants no longer can prevent a clot from
forming.

CLOT RETRACTION AND DISSOLUTION

After a clot has formed, it begins to condense into a denser compact structure by a process
known as clot retraction. Serum, which is plasma without its clotting factors, is squeezed out of the clot
during clot retraction. Consolidation of the clot pulls the edges of the damaged vessels together,
helping the stop of the flow of blood, reducing the probability of infection and enhancing healing. The
damaged vessel is repaired by the movement of fibroblasts into damaged area and the formation of the
new connective tissue. In addition, epithelial cells around the wound divide and fill in the torn area.

The clot is dissolved by a process called fibrinolysis. An inactive plasma protein called
plasminogen is converted to its active form, which is called plasmin. Thrombin and other clotting
factors activated during clot formation, or tissue plasminogen activator released from surrounding
 tissues, stimulate the conversion of plasminogen to plasmin. Over a period of a few days the plasmin
slowly breaks down the fibrin.

PATHOPHYSIOLOGY

Precipitating Factors: Age

Male
Predisposing Factors: Immuno compromized
Environment

Bite of a aedes aegypti mosquito carrying a virus

↓
Virus goes into circulation
↓
Dengue Virus Type II
↓
IgG adheres to the platelet
↓
thrombocytopenia
↓
increased potential for hemorrhage
↓
stimulates intense inflammatory response
↓
petechial rash, high fever, headache,vomiting, abdominal pain, (+) torniquet test

VI. Nursing Assessment

Name: Reuben Gabriel Dagoldol Date: July 8,2010
Vital Signs: Pulse: 132bpm RR: 28cpm Temp: 38.6˚C Height: Not obtained Weight: 13kgs
EENT:
 oleObject1 [ ] impaired vision [ ] blind
Flushed skin

Fever (38˚C)

Warm
restlesness
Fatigue

[ ] pain [ ] reddened [ ] drainage

[ ] gums [ ] hard of hearing [ ] deaf
[ ] burning [ ] edema [ ] lesion [ ] teeth
Assess eyes, ears, nose, throat
For abnormality [x] no problem
RESPIRATORY
[ ] asymmetric [ ] tachypnea
[ ] apnea [ ] rales [ ]cough[ ] barrel chest
[ ] bradypnea [ ] shallow [ ] rhonchi
[ ] sputum [ ] diminished [ ]dyspnea
[ ] orthopenea [ ] labored [ ]wheezing
[ ] pain [ ] cyanotic
Assess resp.rate, rhythm, depth, pattern
Breath sounds, comfort [ x] no problem
CARDIOVASCULAR
[ ] arrhythmia [ ] tachycardia [ ] numbness
[ ] diminished pulses [ ] edema [x ] fatigue
[ ] irregular [ ] bradycardia [ ] murmur
[ ] tingling [ ] absent pulses [ ] pain
Assess heart sounds, rate, rhythm, pulse,
circulation, fluid retention, comfort [ ] no
GASTRO INTESTINAL TRACT
[ ] obese [ ] distention [ ] mass
 oleObject2 [ ] dysphagia [ ] rigidity [ ] pain
Assess abdomen, bowel habits, swallowing,
Bowel sound, comfort [ } no problem
Gyn-bleeding, discharge [x] no problem
NEURO
[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures
[ ] lethartic [ ] comatose [ ] vertigo [ ] tremors
[ ] confused [ ] vision [ ] grip
Assess motor function, sensation, LOC, strength,
Grip, gait, coordination, orientation, speech [x] no problem
MUSCULOSKELETAL and SKIN
[ ] appliance [ ] stiffness [ ] itching [ ] petechiae
[x ] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [ ] poor turgor [ ] cool [ ] deformity
[] wound [ ] rash [ ] skin color [ x] flushed
[ ] atrophy [ ] pain [ ] eccymosis [ ] diaphoretic [ ] moist
Assess mobility, motion, galt, alignment, joint function/
Skin color, texture, turgor, integrity [ ] no problem

Nursing Assessment II
SUBJECTIVE OBJECTIVE

Communication: [ ] glasses [ ] language

[ ] hearing loss [ ] visual changes [ ] contact lens [ ] hearing aide
[ ]denied R L
Comments: “wala may problema sa pandungog ug Pupil size : 3mm
panan aw sa akong anak “as verbalized by the Reaction: Pupil equally round reactive to light and
mother. accommodation.
[ ] speech difficulties
Oxygenation:
[ ] dyspnea [ ] smoking history [ ] cough [] Respiratory [ x] regular [ ] irregular
sputum [ ] denied Describe: Respirations are regular 25cpm within the
Comments: “dli man galisod ug ginhawa akong anak normal range.
“as verbalized by the mother. R: Normal symmetrical breathing
L: Normal symmetrical breathing
Circulation: Heart Rhythm [x] regular [ ]irregular
[ ] chest pain [ ] leg pain Ankle Edema: none
[ ] numbness of extremities Pulse Car. Rad. DP. Fem.*
[ ] denied R :+ 132 + + _+
Comments: “di man gasakit ang dughan sa akong L :+ 132 + + +
anak“as verbalized by the mother. Comments: Normal and palpable pulses

Nutrition:
Diet: as tolerated [ ] dentures [x] none
Character: [ ] recent change in weight, Full Partial With Patient
appetite Upper [] [] []
[ ] swallowing difficulty [ ] denied Lower [] [] []
Comments: “ gasuka siya pero dili kaayo”as
verbalized by the mother.
Elimination:
Usual bowel pattern Urinary frequency Bowel sounds: Audible bowel sound
Once a day 3 times a day Abdominal Distention
constipation remedy [ ] urgency Present [ ] yes [ x] no
n/a [ ] dysuria Urine* (color, consistency, odor)
Date of last BM [ ] hematuria *if they are in place
Dec. 8, 2009 [ ] incontinence Comments: The urine is normal and yellow color.
Diarrhea character: [ ] polyuria
None [ ] foley in place
[ ] denied

Management of Health and Illness:

[ ] alcohol [ ] denied Briefly describe the patient’s ability to follow
(amount, frequency) treatments (diet, meds, etc.) for chronic health
Comments: N/A problems (if present).
[ ] SBE Last Pap Smear: N/A The client follow strictly the medication and diet as
LMP: N/A prescribed by the physician.

SUBJECTIVE OBJECTIVE

Skin Integrity: [ ] dry [ ] cold [x] pale [ ] flushed

[ ] dry [ ] itching [ ] denied [ x ] warm [ ] cyanotic
Comments: “wala man siya gapangatol” As verbalized *rashes,ulcers, decubitus (describe size, location,
by the mother. drainage) The patient has no rashes in upper and
 lower extremities.
Activity/ Safety: LOC and orientation:
[ ] convulsion [ x] dizziness Patient is conscious.
[ ] limited motion of joints Gait: [ ] walker [ ] cane [ ] other
Limitation inability to: [x ] steady [ ] unsteady
[ ] ambulate [ ] bathe self [ ]sensory and motor losses in face or extremities:
[ ] other [ ] denied none
Comments: “Ga kapoy ang iyang lawas as” verbalized [ ]ROM limitations: no range of motion is limited
by the mother.
Comfort/ Sleep/ Awake
[ ] pain (location, frequency, remedies) [ ] facial grimaces
[] nocturia [ ] sleep difficulties [ ] denied [ ] guarding
Comments: “Dili man siya galisud pag matulog,” as [ ] other signs of pain: none
verbalized by mother. [ ] siderail release form signed ( 60 + years ) N/A
Coping: Observed non- verbal behavior:
Occupation (mother): none none
Members of household: 3 The person and his phone number that can be
Most supportive person: Mr. Ephy Tuto reached any time: Not obtained.

VII. Nursing Management

A. Ideal Nursing Management

1. Hyperthermia r/t infection

Interventions Rationale
 Independent:
•Limit physical activity •This will help lower down temperature
•
•Increase fluid intake as tolerated •Help lower down the temperature and prevent
hypovulemia
•Perform TSB •This will help lower down the body temperature
•This will help relxed the patient
Provide fresh air if necessary by opening the windows
if ever there's a window
To prevent from sweating.
Let patient wear light clothings

Dependent:
1. Administer prescribed medications as ordered •To help reduce the temperature
(Paracetamol) such as Calpol 5ml PRN for fever

2. Acute pain related to inflammatory response

Interventions Rationale
 Independent:
Monitor vital signs
To determine alteration

Instruct deep breathing exercise Helps in relieving pain

Encourage to have diversional activites like To divert attention of patient from pain
watching t.v.
Helps reduce pain felt

Place patient on comfortable position

For relaxation and to prevent stress

Encourage to have adequate bed rest To provide comfort

Provide therapeutic touch Helps in relieving pain

Dependent: •
•Administer Maalox as ordered 3x a day 5ml PO

3. Fluid Volume Deficit related to frequent loss of fluid in the gastrointestinal tract as evidenced by frequent
vomiting.
Interventions Rationale
Independent:
Independent: Ensure accurate picture of fluid status

Monitor Intake and Output

To prevent irritation in stomach.

To determine if the stomach can already tolerate

Withhold foods and fluids for about 3 hours. fluids
 Instruct to sip small amounts of fluids after three To relieve hunger due to the fasting done.
hours fasting.

Instruct to give crackers and toasted bread. Prevents fluctuation in fluid levels

B. ACTUAL NURSING MANAGEMENT

S ”Gihilantan mana siya" as verbalized by patients mother..
O •pale skin
•T-38.6
•Warm skin to touch
A Hyperthermia r/t infection
P Long term: At the end of 3 days of care, client's mother will know how to prevent fever
Shot term: At the end of 30 minutes nursing intervention, the patient’s body temperature will decrease
into normal range
I Independent:
1. Use preventive measures:
a. Remove hard toys from the bed
b. Pad the sides of the crib or side rails of the bed
c. Have a suction machine available to remove secretions during seizure
d. Have an emergency oxygen source in the room in case of sudden respiratory difficulty

2. Make sure that the child can be readily observed

3. During a seizure, monitor vital signs and assess neurologic status frequently
4. Following a seizure, check the child frequently and report the ff:
a. Behavior changes
 b. Irritability
c. Restlessness
d. Listlessness

Dependent:
•Given bronchodilators (Salbutamol) as ordered, to relax bronchial smooth muscles thus facilitating
airflow.

E After 30 minutes, the client’s body temperature will be lower down to prevent seizure.

S ”Galisod siya kaginhawa kung muatake na iyang convulsion” as verbalized by the mother.

O Dyspnea

A Ineffective breathing pattern RT spasms of respiratory musculature

P Long term: At the end of 2 days of care, patient will be able to resume daily activities by not having a
fever to prevent seizure
Short term: At the end of 30 minutes nursing intervention, client will have a effective breathing pattern
I Independent:
1. During a seizure take the following emergency actions:
a. Clear the area around the child
b. Do not restrain the child
c. Loosen the clothing around the neck
d. Turn the child on side so that saliva can flow out of the mouth
e. Place a small, folded blanket under the head to prevent trauma if the seizure occurs when the
child is on the floor.

2. Suction the child, and administer oxygen as necessary

3. Do not give anything by mouth or attempt to place anything in the mouth.
4. After the seizure, place the child in a side lying position.

Dependent
1. Maintained supplemental oxygen therapy as ordered
 E After 30 minutes, client will have a effective breathing pattern

S ” Maulaw siya sa kapag mu atake ang convulsion.” as varbalized by the mother.

O
•crying
•restlessness
A Social Isolation related to the child’s feelings about seizures or public fears and misconceptions

P Long term: At the end of 2 days nursing care, the patient will have develop to socialize with people
Short term: At the end of 8 hours of nursing intervention, the patient will develop and learn that he must
socialize to other people

I Independent:
•Advise the parents that the child should be in an environment that is as normal as possible
•Encourage regular attendance at school after the school nurse and teachers have been notified, and
emergency treatment of seizures is understood.
•Encourage the child to participate in organizations and outside activities with limited restrictions.
a. Each child must be treated individualy; the kind of activity depends on the degree of control.
b. Generally, the children with seizure disorders should not be allowed to climb in high places or
to swim alone.
c. Responsible adults should be made aware of the child’s disorder.

E After 8 hours of nursing interventions, the goal was achieved by seeing the patient socializing to
other people
 S ”Gihilantan man ni siya” as verbalized by the mother of the patient.
O •Flushed skin
•Warm to touch
•Temp. (38˚ C)
A Hyperthermia related to infection as evidenced of temp. above normal range
P Long term: At the end of 2 days of care, client temperature will maintain in normal range.
Shot term: At the end of 30 minutes of nursing intervention, the patient temperature will lower down from
38˚ C to 37˚ C.
I Independent:
1. Apply Tepid Sponge Bath
2. Increase fluid intake
3. Monitor body temperature
4 Let wear light clothings
5. Provide well ventilated room
6. Limit physical activities

Dependent:
5. Given Paracetamol as ordered, to help lower the temperature therapeuticcaly.

E After 30 minutes of nursing intervention, the patient temperature was lower down from 38˚ C to 37˚ C.

VIII. REFERRALS & FOLLOW-UP

• HEALTH TEACHINGS
 MEDICATIONS •Encourage the patient's mother the need for religious adherence to medication
regimen
•Explain to the patient each medication prescribed.
•Explain proper administration of medication according to its route (e.g. oral, topical)
together with the knowledge about potential side effects

EXERCISE •Encourage patient's mother to avoid excessive stress and have adequate rest and
sleep.

•Encourage the patient to perform self-hygiene activities

TREATMENT •The patient instructed to religiously facilitate in taking the prescribed home
medication on time as ordered.
•Instruct to observe proper food preparation or proper sanitation.

OUT-PATIENT •Emphasize importance of keeping schedule appointments with health care providers
(Check-Up)
1 week after discharge especially when there are noticeable changes in the condition
and refer to Dr. Neri

DIET •Encourage the patient's mother eat nutritious food such as vegetable and fruits

•Instruct the patient's mother to maintain proper diet that he can tolerate, such as
fruits, to help promote wellness.

•Advice patient's mothert to monitor fluid intake or adequate hydration, to help her
body re-hydrate to prevent fluid imbalance.

•Advice patient's mother to have proper nutrition to enhance immune.

IX. EVALUATION AND IMPLICATIONS

Being exposed to the hospital specifically at pediatric ward as nursing students to care for
pediatric ill patients, we have encountered many interesting cases that would surely enriched our
nursing knowledge and skills, and Dengue is one of those problems.
 In a sense that I am a future health care provider, it is crucial in my part that I see to it and
identified the health problem of my patient, which is significant in my nursing field and study,
somehow I was able to identify nursing diagnosis and implemented possible effective nursing care,
which gave sense of accomplishment in my part as student nurse. Eventually, I should be cautious at all
times in giving care to my patient and should always bear in mind that I am dealing with life. And must
always be compassionate and provide holistic approach.
This study will serve as a reference material in rendering competent care to my client
especially those with similar situation. Through this, I will be able to develop my knowledge as well as
my skills and attitudes in applying the prescribed procedure to improve the health status of the patient.
This study will act as a baseline as well as a guide for coming up with a good, reliable,
accurate and comprehensive research paper dealing with issues commonly experienced by patient in
the hospital setting. This may aid the researchers to widen the scope of the study in relation to more or
less similar cases. The case study paved way for researcher to identify and determine issues related to
benign febrile seizure.

X. BIBLIOGRAPHY
A. BOOKS

• Barbara Kozier; “Fundamentals of Nursing” 7th edition

• Smeltzer, Suzanne. Medical-Surgical Nursing, 11th edition

• The Lippincott Manual of Nursing Practice 6th Edition

• Springhouse corporation Disease and Disorders Handbook

• WEBLIOGRAPHY

http://emedicine.medscape.com/article/927340-overview

www.nursingcrib.com

www.yahoo.com

www.wikipidia.com.dengue Fever
Rating Scale

A. WRITTEN WEIGHT RATING

I. Introduction 5
a. Overview of the Case
b. Objective of the Study
c. Scope and Limitation of the Study
II. Health History 5
•Profile of the Patient
•Family and Personal Health History
•Chief Complaint
III. Developmental Data 5
IV. Medical Management 20
•Medical Orders with Rationale (10)
•Drug Study (10)
V. Pathophysiology with anatomy and physiology 10
VI. Nursing Assessment 10
•Nursing System Review Chart 30
•Nursing Assessment II (10)
VII. Nursing Management (20)
•Ideal Nursing Management
•Actual Nursing Management
VIII. Referrals and Follow-up 5
IX. Evaluation and Implication 5
X. Documentation 5
a. Documentation of Evidence of Care for 1 Week Rotation
b. Organization/Grammar/Bibliography
Total Score
Equivalent Grade