Академический Документы
Профессиональный Документы
Культура Документы
__________________________
Submitted to:
Mr. Ryan E. Aliwalas, RN
In Partial Fulfillment
of the Requirement for the Course
NCM 101
RLE
H-Vill Hospital
Submitted by:
Gomez, Richerylle C.
Gutierrez, Floren Angelie V.
Hernandez, Richelle Joy T.
Hussin, Johanna Fariza T.
Ison, Sheila May H.
Javier, Jayson R.
Jayme, Carolyn Eleanor F.
Labide, Prima Encar T.
Ladjahasan, Irish Princess A.
Lagumbay Joanne B.
Lardillo, Catherine A.
Lomocso, Jamielyn Kate B.
GROUP 7
AUGUST 2009
INTRODUCTION
GOAL
General Goal:
Specific Goal:
Name: CJS
Age: 13 years old
Gender: Male
Address: # 32 Natividad St. Malanday San Mateo, Rizal
Date of Birth: October 24, 1995
Place of Birth: Marikina
Nationality: Filipino
Religion: Roman Catholic
Civil Status: Single
Occupation: N/A
Date of Admission: August 24, 2009
Time of admission: 9:00 pm
Physician: Dra. Del Valle
Place of Admission: H-Vill Hospital
Admitting Diagnosis: Dengue Fever Syndrome
a.1 CHIEF COMPLAIN
• The patient complains of abdominal pain, headache, fever and general
flushing of skin with on and off vomiting.
C. HISTORY OF ILLNESS
• During the mid of August, CJS, started experiencing fever that persist only
at night. As a remedy his mom gave him Paracetamol to lower his body
temperature. Except from fever he’s also experiencing abdominal pain,
headache and general flushing of the skin with on and off vomiting.
As the above signs and symptoms persists, his parent decided to bring
him to the hospital.
Application Theory:
The case of CJS can be correlated with the theory of Nightingale wherein,
the environment of the patient is a factor leading to recovery. Having a clean,
well ventilated and quite environment is important in. With a nurturing
environment, the body could repair itself.
PHYSICAL EXAMINATION
PHYSICAL ASSESSMENT
I. LINEAR MEASUREMENT
1. Height: 5’4’’
2. Weight : 51kgs.
PHYSICAL ASSESSMENT
NAME: CJS
DATE OF ASSESSMENT: August 24, 2009
VITAL SIGNS:
BP: 10070 mmHg PR: 76bpm
RR: 22bpm Temp: 36.5˚C
General Appearance: Received lying on bed, conscious and coherent. Pale and has general flushing with rashes
Area assessed Technique
Used
Normal Findings Actual Findings Rationale
HEAD
Size Inspection Proportion to the body Proportion to the Normal
Symmetry Inspection and the skull is body Normal
rounded and smooth and the skull is
Symmetrical rounded
and smooth
HAIR Symmetrical Normal
Color Inspection Black No nits/lice present Normal
Texture Inspection Curly hair, straight Normal
Other findings Inspection No nits/lice present
SCALP
Distribution of hair Inspection Evenly distributed No inflammation, Normal
Lesions Inspection No inflammation, lumps Normal
Other findings Inspection lumps or masses or masses Normal
FACE
Skin color Inspection Light to deep brown Pinkish Due to fever
Texture Inspection Smooth Symmetric facial Normal
Facial movement Inspection Symmetric facial Symmetric facial Normal
movement movement
EYES
External structure Inspection Evenly distributed
Eyebrows Inspection Evenly distributed, Pink conjunctiva Normal
Eyelashes Inspection Evenly distributed, curved outward Evenly distributed Normal
Eyelids Inspection Evenly distributed Normal
MOUTH Symmetric
Lips Inspection Pink Symmetric
Symmetry Inspection Moist Pink Normal
Moisture Inspection Dry Normal
D/t poor
TONGUE Positioned at the nutrition
Position Inspection center can move Central position
Color Inspection freely Dull red Normal
Texture Inspection Dull red Smooth Normal
Mobility Inspection Smooth Can move freely Normal
Lesions Inspection Can move freely No lesions or Normal
No lesions or inflammation Normal
inflammation
Normal Normal
GORDON’S 11 FUNCTIONAL HEALTH PATTERN
PATHOPHYSIOLOGY
↓
Bite of a aedes aegypti mosquito carrying a virus
↓
Virus goes into the circulation
↓
Infects cells & generate cellular response
↓
Initiates destruction of the platelet
↓
↑ Potential for hemorrhage
↓
Stimulates intense inflammatory response
▼ ▼
Release of exogenous pyrogens The body releases anti-
↓ inflammatory mediators
↑ WBC (Neutrophils & Macrophages) (Histatin, Kinins)
↓ ↓
Release of endogenous pyrogens Vascular response
↓ ↓
Reset of hypothalamic thermostat Redness & Heat
↓ ↓
Fever Headache, Vomiting
▼ ▼ Epistaxis, Abdominal pain
Muscle contract Blood vessels Circulatory Collapse Shock
To produce construct to ↓
Additional heat prevent loss of body heat DEATH
↓ ↓
SHIVERING CHILLS
Discharge Planning
A. Patient's Name:
> C.J.S a thirteen year-old male patient, who was diagnosed with Dengue
Hemorrhagic Fever.
B. Diet:
> Encourage nutritious foods like vegetables, meat and fruits.
C. Medications:
> Give acetaminophen in case the temperatures increases.
> Give oresol to replace fluid in the body.
D. Treatment:
> Increased oral fluid intake.
E. Health Teaching:
> D- discuss the possible source of infection of the disease.
> E- educate the family/patient on how to eliminate those vectors.
> N- Never stocked water in a container without cover.
> G- Gallon, container and tires must have proper way of disposal.
> U- Use insecticides at home to kill or reduce mosquito.
> E- Encourage the family of the patient to clean the surroundings to destroy the
breeding places of mosquito.
General
This case presentation aims to identify and determine the general heath problems and
needs of the patient with an admitting diagnosis of Dengue Hemorrhagic Fever, Type 1.
This presentation also intends to help patient promote health and medical understanding
of such condition through the application of the nursing skills.
Specific
• To raise the level of awareness of patient on health problems that she may
encounter.
• To facilitate patient in taking necessary actions to solve and prevent the identified
problems on her own.
• To help patient in motivating her to continue the health care provided by the
health workers.
• To render nursing care and information to patient through the application of the
nursing skills.
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 that feels like bones are breaking, hence
the name. Health experts have known about dengue fever for more than 200 years.
INTRODUCTION
Dengue fever is found mostly during and shortly after the rainy season in tropical and
subtropical areas of
• Africa
• Southeast Asia and China
• India
• Middle East
• Caribbean and Central and South America
• Australia and the South and Central Pacific
An epidemic in Hawaii in 2001 is a reminder that many states in the United States are
susceptible to dengue epidemics because they harbor the particular types of mosquitoes
that transmit it. Worldwide, more than 100 million cases of dengue infection occur each
year. This includes 100 to 200 cases reported annually to the Centers for Disease Control
and Prevention (CDC), mostly in people who have recently traveled abroad. Many more
cases likely go unreported because some health care providers do not recognize the
disease. During the last part of the 20th century, many tropical regions of the world saw
an increase in dengue cases. Epidemics also occurred more frequently and with more
severity. In addition to typical dengue, dengue hemorrhagic fever and dengue shock
syndrome also have increased in many parts of the world.
Dengue fever can be caused by any one of four types of dengue virus: DEN-1, DEN-2,
DEN-3, and DEN-4. You can be infected by at least two, if not all four types at different
times during your lifetime, but only once by the same type.
You can get dengue virus infections from the bite of an infected Aedes mosquito.
Mosquitoes become infected when they bite infected humans, and later transmit infection
to other people they bite. Two main species of mosquito, Aedes aegypti and Aedes
albopictus, have been responsible for all cases of dengue transmitted in this country.
Dengue is not contagious from person to person.
Symptoms of typical uncomplicated (classic) dengue usually start with fever within 5 to 6
days after you have been bitten by an infected mosquito and include
The rash may appear over most of your body 3 to 4 days after the fever begins. You may
get a second rash later in the disease. Symptoms of dengue hemorrhagic fever include all
of the symptoms of classic dengue plus
Symptoms of dengue shock syndrome-the most severe form of dengue disease-include all
of the symptoms of classic dengue and dengue hemorrhagic fever, plus
This form of the disease usually occurs in children (sometimes adults) experiencing their
second dengue infection. It is sometimes fatal, especially in children and young adults.