GRAND CASE PRESENTATION ON

DENGUE FEVER
G2A Group I Abu, April Lyn O. Agdan, January D. Agojo, Anna Jeanelle C. Alas, Cyrin A. Albiola, Patricia V. Alcantara, Deanna Rose H. Alcaraz, Arianne C. Anzo, Ferdinand M. Aquino, Kenneth S. De Castro, Aina Martina R. Clinical Instructor Ms. Ruby Anne Chavez R.N., M.A.N. Area of Exposure Lipa Medix Medical Center OPD Date March 15-18, 2010 (6am-2pm)

TABLE OF CONTENTS Introduction................................................... Demographic Profile/History............................................... Physical Assessment............................................... Anatomy and Physiology............................................ Pathophysiology..................................................................... Laboratory and Diagnostic Procedures................................................ Medical Management....................................................... Drug Study...................................................... Nursing Care Plan.............................................................................. Summary of Discharge....................................................................................................

General Objectives: This case presentation aims to identify and determine the general health problems and needs of the patient with an admitting diagnosis of Dengue Febrile Syndrome, Stage 1. This presentation also intends to help patient promote health and medical understanding of such condition through the application of the nursing skills. Specific Objectives:
To enhance the knowledge and skills on proper assessment of signs and symptoms of Dengue Febrile Syndrome. To formulate the appropriate nursing diagnosis of Dengue Febrile Syndrome.

To differentiate proactive management by anticipating and planning for eventualities of condition/potential complications.
To identify the proper medical and nursing management, the independent, dependent as well as the collaborative

intervention for Dengue Febrile Syndrome. To evaluate clients progress towards attaining the identified outcomes. 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.

I. Introduction Dengue Fever is a viral disease found in most tropical areas of the world, mostly in urban and semi urban region. The virus is contracted from the bite of a striped Aedes Aegypti mosquito that has previously bitten an infected person. This mosquito is usually found in or near human habitation and prefers to bite at anytime during the day. This mosquito breed in our backyards, in our drainage canal, in places such as cans, flower pots and tires with stagnant water and even potholes during the rainy season. It is considered as the second deadliest mosquito borne disease next to malaria. Dengue Fever is characterized by the sudden onset of fever and symptoms like headache, body weakness, characteristics rashes, nausea and vomiting, muscle and joint pain. The severity of the joint pain has given dengue breakbone fever The dengue virus has four serotypes (types 1, 2, 3, and 4) which means that you may be infected with dengue virus four times in your life. Recovery from infection by one dengue serotype will give lifelong immunity against that serotype but only partial and transient protection against subsequent infection by the three other groups. Global Significance The World Health Organization (WHO) issued a warning that due to climate change, the mosquito borne dengue disease has become unstoppable. Inflicting itself on over 50 million individuals worldwide, with over 24, 000 mortalities a year, the WHO says warming has resulted in increased mosquito populations. The WHO said tropical countries like Philippines are particularly at risk. Aside from climatic changes, the major drivers of global dengue are population growth and lack of effective mosquito control. Local Significance In the Philippines, Health Secretary Francisco T. Duque III revealed that the Philippines experienced an alarming rise in reported dengue cases in 2007 when there were over 45, 300 cases and 416 deaths. It was the second worst year for dengue following the first one in 1998. But the DOH has been working with local governments and community leaders to eliminate stagnant water and other possible mosquito breeding site. Because of the continuing anti dengue campaign, the number of reported cases in the country has declined with a 37 percent decrease in cases last August from the same period last year. As of September 1 2009, there were a total of 16, 317 dengue cases reported nationwide, compared 25, 969 reported from the same period last 2008. Mortality Rate

Anyone who is bitten by an infected mosquito can get dengue fever. It affects people regardless of age groups but majority of the cases are among children 0 15 years old. Risk factors for dengue hemorrhagic fever include a person's age and immune status, as well as the type of infecting virus. Persons who were previously infected with one or more types of dengue virus are thought to be at greater risk for developing dengue hemorrhagic fever if infected again. When treated, DHF/DSS is associated with a 3% mortality rate but when left untreated, DHF/DSS is associated with a 50% mortality rate. Ethnicity is a non specific but the diseases distribution is geographically determined. Fewer Cases have been reported in the black population than in other races. No predilection is known; however, fewer cases of DHF/DSS have been reported in men than in women.

References: Philippine Daily Inquirer, What is the natural cause of dengue infection and what are its implications? by Dr. Ma. Luisa Manlapaz, January 24, 2008. Philippine Daily Inquirer, What is Dengue? by Dra. Pamela Santiago, pp. C- 3, June 10, 2008. Manila Bulletin, Stemming the tide of Dengue, p. 11, September 23, 2009 Manila Bulletin, Dengue, p. 11 by Dr. Gary S. Sy, August 8, 2007 Manila Bulletin, Department of Health warns against Dengue p.10, May 19, 2009.

II. Demographic Profile Name: Address: Birthday: Age: Status: Religion: Admitting Weight: Present Weight: Educational Attainment: Chief Complaint: Admitting Diagnosis : Final Diagnosis: Date and Time of Admission: Admitted By: Attending Physician: PATIENT EYL 377, Brgy. 7, Granja, Lipa City, Batangas December 9, 1998 11 y/o Child Roman Catholic 31 kgs. 30.9 kgs. Grade 5 pupil Fever for 5 days Dengue Fever Syndrome Stage 1 Dengue Fever and UTI March 12, 2010, 4:32PM Ms. Hanabel T. Adano Dr. Romualdo Reyes M.D.

History a. History of Present Illness Five days prior to admission, the patient experienced fever with headache and epigastric pain. The temperature was not checked by her mother but she said that her child is warm to touch. The intensity of pain, according to the client, is 4/10 as 1 is the lowest and 10 is the highest. The mother of the patient gave Paracetamol to lower the body temperature of the client. After giving Paracetamol, the body temperature of the patient decreases. The headache and epigastric pain also lessen. The client still experienced fever, headache and epigastric pain on the fourth, third and second day prior to admission. Because of the continuous fever for five days, the parents decided to admit the patient in the hospital at Lipa Medix Medical Center in the service of Dr. Romualdo Reyes. According to the father of the patient, they do not know where the child acquired the disease. They suspected that the client was afflicted by the disease in her school because of the presence of mosquito breeding sites in the area. b. Past Medical History The patient was not exposed to diseases such as chickenpox, mumps, and measles. But she experienced cough, cold, and fever when she was a child. The client has no known allergies to drugs, foods, animals, insects and other environmental agents. There was no accident or injuries happened to the patient. When the patient was two years old, she was admitted to the hospital because of dehydration. She also took medications prescribed by the physician such as Paracetamol for fever.

c. Genogram with Family History

40 y/o Kidney disease

72y/ A&

74y
65y/o Liver Cancer

/o
Parkinsons disease

39y/o UTI 18y /oA &W ` 17y /oA &W LEGEND: Male Died 16y /oA &W

38y /oA &W

Female Patient

The grandfather of the patient on the father side died at 40 years old because of kidney disease. Her grandmother is alive and well and she is 72 years old. On the other hand, her grandfather on the mother side died because of liver cancer at the age of 65. The grandmother is 74 years old and suffering from Parkinsons disease. The father of the patient, at the age of 39, was undergone cholecystectomy and has UTI. The mother of the patient is alive and well at the age of 38. The patient has three siblings and she is the youngest. Her three siblings are all alive and well with the age of 18, 17, and 16. The patient, at the age of 11, has Dengue Febrile Syndrome. But the diseases of her grandparents were not inherited by her. d. Social Data In times of needs, patient EYL merely seeks comfort from her family, especially to her mother. She often chooses to be alone. The patient belongs to the extended type of family where they live together with her cousins. Because of the clients illness, her family became worried and cannot sleep well for three days. Environment also contributes a lot to an individuals help. The family always put their trust in God. In terms of cultural practices, the mother of the patient used herbal medicines because of its cheap cost. The father of patient EYL is company driver while her mother was a midwife and caregiver. According to the father, the family is experiencing financial crisis sometimes. There times that the parents cannot sustain the needs of the children. They sometimes cannot give the exact allowance they needed. But despite of those family difficulties, the mother and father of patient EYL tried to do their best and work harder to meet the needs of their children. The patient is enrolled in schools and a grade 5 student. She always plays with her friends and classmate.

e. Lifestyle The patient has an inappropriate diet. She drinks cola five times a week. She also loves to eat junk foods, bread, and crackers and drinks juices. She drinks only three glasses of water every day. She eats rice thrice a day and has snacks anytime she wanted. She often eats fish and meat during meals, but seldom eats vegetables. The foods she eats were often cooked by her mother. She has no allergies in the food she ate. In terms of sleep /rest pattern, the client has no sleep difficulties. She usually sleeps at around 10 oclock in the evening and wake up at 6 oclock in the morning. As part of her hobbies, the patient loves to play jackstone with her friends and watch television. She is also fond of dancing, singing, and reciting poems. The hygiene practices were done by the patient alone. She takes a bath daily before going to school to maintain good personal hygiene. f. Psychological Data The client has a weak personality. According to the mother, patient EYL usually cries when she is scolded. She easily became depressed and chose to be alone when problem arises. But despite of those attitudes at home, the patient became friendly in school. She has many playmates and friends. She was known being a good person and an active student. During her confinement, patient EYL became meek and weak. She merely talks to others, especially to nurses. We often see her sleeping because of the pain she was into. g. Patterns of Health Care During health problems, the patients family seek consultation first from herbolarios. They use herbal plants like oregano for cough. They also use over the counter drugs such as Paracetamol for fever and Neozep for colds. But, if the

disease/illness was not treated well, the family seek the advice of health care professionals for medical assistance. After the medical check-up, the family then decides if they will admit the client to the hospital. h. Developmental History 1. Erik Eriksons Psychosocial Stage (Industry versus Inferiority) Industry versus Inferiority is Erikson's fourth developmental stage, which takes place from age 6 to 11, involves the shift from whimsical play to a desire for achievement and completion. A child learns that he receives praise and recognition for doing well in school and completing tasks and also realizes he can fail at these tasks as well. Through social interactions, children begin to develop a sense of pride in their accomplishments and abilities. Children who are encouraged and commended by parents and teachers develop a feeling of competence and belief in their skills. Those who receive little or no encouragement from parents, teachers, or peers will doubt their ability to be successful. The patient is under industry versus inferiority because she is fund of interacting and playing with her schoolmates. She is active in school activities like participating in a singing and dancing contest. She gain praise from her family especially to her mother for doing well in school and completing tasks. Patient EYL is a creative person in the sense that she is good in showing her abilities. She is competent enough to show her talent in school such as dancing and singing. But when she is at home and doing her assignments, her parents notice that the child do not exert too much effort on it. 2. Sigmund Freuds Psychosexual Stages (Latency Stage) During the latent period, the libido interests are suppressed. The development of the ego and superego contribute to this period of calm. The stage begins around the time that children enter into school and become more concerned with

peer relationships, hobbies, and other interests. The latent period is a time of exploration in which the sexual energy is still present, but it is directed into other areas such as intellectual pursuits and social interactions. This stage is important in the development of social and communication skills and self-confidence. The client is under latency stage of Sigmund Freud because when she is studying, she is more concerned with her friends, hobbies and interests. She likes to play with her friends at school. 3. Jean Piagets Cognitive Development Theory The concrete operational stage begins around age seven and continues until approximately age eleven. During this time, children gain a better understanding of mental operations. Children begin thinking logically about concrete events, but have difficulty understanding abstract or hypothetical concepts. Piaget determined that children in the concrete operational stage were fairly good at the use of inductive logic. Inductive logic involves going from a specific experience to a general principle. On the other hand, children at this age have difficulty using deductive logic, which involves using a general principle to determine the outcome of a specific event. One of the most important developments in this stage is an understanding of reversibility, or awareness that actions can be reversed. An example of this is being able to reverse the order of relationships between mental categories. The client knows that she is sick but she has lack of knowledge on her disease. She doesnt know the severity of her disease.

III. Physical Assessment Body Part

General Physical Observation Physical Development Behavior Mood Body Built

(March 15-16, 2010) Method Use

Inspection Inspection Inspection Inspection

Findings
Appears to the stated chronological age (11 y/o) Cooperative attitude and behavior Approachable and cooperative Small framed, muscles are firm and well developed 31 kg

Interpretation
Normal Normal Normal Normal

Weight Admitting:

Inspection

Normal

IBW: 30 kg - Present: General Observation Posture Facial Expression

Inspection Inspection Inspection

30.9 kg Posture is upright, attentive Eye contact is maintained, client smiles with appropriate facial expressions No wounds, no bruises, with petechiae on the upper and lower extremities, dry, good skin turgor With Hermans rashes

Normal Normal Normal

Skin

Inspection

Petechiae is due to ruptured capillaries because of low platelet count Dryness is due to low fluid intake.

Temperature Gait

Palpation

36.2C , afebrile

Gait was not assessed due to patients dizziness.

Normal Dizziness is due to low platelet count. If bleeding occurs there will be less blood volume. If there is blood volume, it results to low blood pressure. Low blood pressure is associated with dizziness. Normal Normal

Hair

Head Scalp

Inspection Inspection Palpation Inspection

Face

Inspection

Neck

Inspection

Round, symmetrical with the body Symmetrical, no lesions Smooth, firm Equally distributed, black in color, fine, no infestations Fairer than the body color, symmetrical, centered head position In midline, controlled movement, full ROM Evenly distributed and curve outward Without redness, swelling or lesions Clear with tiny vessels, moist. Sclera is white Upper and lower

Normal

Normal

Normal

Eyes Eyelashes Eyelids Bulbar Conjunctiva and Sclera Palpebral Conjunctiva

Inspection Inspection Inspection Inspection

Normal Normal Normal Normal

Cornea Lens Iris Pupil Accommodation of Pupils

Inspection Inspection Inspection Inspection Inspection

conjunctiva are clear and free of lesions Transparent with no opacities, moist No opacities, clear Round, flat and evenly colored - dark brown Equal in size, centered in iris, PERRLA Normal pupillary response ( constriction of pupils and convergence of the eyes when focusing on near object Equal in size bilaterally, auricle aligns with the corner of each eye Non tender No discharges Color is same as the face, nasal structure is symmetric, no lesions No tenderness Pt. is able to sniff through each nostril while other is occluded Dry, without lesions or swelling 25 whitish teeth with

Normal Normal Normal Normal Normal

External Ear

Inspection Palpation Inspection Inspection Palpation

Normal Normal Normal Normal Normal Normal

Auricle and Mastoid process Internal Ear Nose External Nose

Patency of Nostrils

Palpation

Mouth

Lips

Inspection Inspection

Dryness is associated with low fluid intake.

Teeth

smooth surfaces and edges, no decayed areas Inspection Inspection Inspection Pink, no lesions, no swelling Pink, moist without lesions Pink, moist, moderate in size with papillae, no lesions, midline fissure present Frontal and maxillary sinuses are non tender Bilaterally symmetrical, no edema, with petechial rashes on both arms Warm to touch, non tender

Normal (Wisdom teeth will appear on adulthood) Normal Normal Normal

Gums Buccal Mucosa Tongue

Sinuses

Palpation

Normal

Arms

Inspection

Palpation

ROM of Arms Radial Pulse Pulse Rate Brachial Pulse Elbows

Palpation Palpation Palpation Inspection

Petechial rashes are due to ruptured capillaries because of low platelet count which is responsible for blood coagulation. Since there is decreased platelet to cause coagulation, capillaries (extremely narrow) burst because of bleeding inside the vessels. Not assessed due to patients dizziness when standing. Have equal strength Normal bilaterally Normal 74 bpm Normal Have equal strength bilaterally Normal Symmetric, without deformities, redness or swelling, free of

Wrists Hands and fingers

Palpation Inspection Inspection

nodules Symmetric, without redness or swelling, free of nodules Finger and nails are symmetric. Fingers lie in straight line. No swelling or deformities. Pink nail beds, round, properly trimmed Immobile, hard Pink tone returns immediately to blanched nail beds in less than 2 seconds when pressure is applied

Normal Normal

Nails

Inspection Palpation

Normal Normal Normal

Capillary Refill

Palpation

Thorax Respiratory Rate Chest Expansion Palpation Palpation 20 cpm Symmetrical expansion (thumbs move apart equal distance in both directions) The patient refused. Clear breath sounds in both lung fields. 90/60 mmHg Normal Normal

Anterior Thorax Posterior Thorax

Auscultation

Normal

Heart Blood Pressure

Auscultation

Normal

Abdomen

Inspection

Genitourinary External Female Genitalia Anus and Rectum Legs Inspection

Abdominal skin is fairer than the body, smooth, free of lesions, umbilicus is midline at lateral line Flat Pain in epigastric region = 4/10 Stool is yellow Urine is light yellow The patient refused.

Patient has minimal intake of food, which is associated with hyperacidity.

Normal

Inspection

The patient refused. With petechial rashes on both legs Pruritus at both legs

Palpation Range of Motion Inspection

Knees

Inspection

No edema present in the legs, equally warm bilaterally, Full ROM (Adduction, flexion, external and internal rotation) Knees symmetric

Petechial rashes are due to ruptured capillaries because of low platelet count which is responsible for blood coagulation. Since there is decreased platelet to cause coagulation, capillaries (extremely narrow) burst because of bleeding inside the vessels. Pruritus is due to activation of histamine.

Normal

Normal

 Feet Inspection

no nodules Toes point forward and lie, aligned with the lower leg, smooth and free of calluses No pain, heat, swelling or nodules. Eyelid covers about 2mm of the iris Eyes move in a smooth, coordinated motion in all directions Bilateral illuminated pupils constrict simultaneously. Pupil opposite the one illuminated constricts simultaneously. Temporal and masseter muscles contract bilaterally Client frowns, smiles, shows teeth, raises eyebrows, movements are symmetrical Client hears whispered words from 1 to 2 ft. She was able to repeat the word whispered to her. Uvula and soft palate rise bilaterally and symmetrically on Normal

Palpation Cranial Nerves CN III (Oculomotor), IV (Trochlear) and VI (Abducens) Inspection

Normal

CN V (Trigeminal) CN VII (Facial)

Inspection Palpation Inspection

Normal Normal

CN VIII (Vestibulocochlear)

Inspection

Normal

CN IX (Glossopharyngeal) and X (Vagus)

Inspection

Normal

CN XI (Spinal Accesory)

Inspection, Palpation

CN XII (Hypoglossal)

Inspection, Palpation

phonation. Gag reflex is present There is symmetric, strong contraction of the trapezius muscles. Resistance is felt when patient turns head to the left and right. Tongue movement is symmetric and smooth. Bilateral strength is apparent.

Normal

Normal

Motor and Cerebellar Systems Coordination Musculoskeletal Temporomandibular Joint Rombergs Test

Not assessed due to patients dizziness when standing. Inspection, Palpation Smooth movement bilaterally on opening, with no clicks or pain Normal

Not assessed due to patients dizziness when standing.

Summary of Abnormal Findings With petechiae on both upper and lower extremities Petechial rashes are due to ruptured capillaries because of low platelet count which is responsible for blood coagulation. Since there is decreased platelet to cause coagulation, capillaries (extremely narrow) burst because of bleeding inside the vessels. Dry skin caused by patients low fluid intake Dry lips - Dryness is associated with low fluid intake. Gait - Dizziness is due to low platelet count. If bleeding occurs there will less blood volume. If there is blood volume, it results to low blood pressure. Low blood pressure is associated with dizziness. Abdominal pain Patient has minimal intake of food, which is associated with hyperacidity. Pruritus at both legs - Pruritus is due to activation of histamine.

IV. Anatomy and Physiology

Circulatory System System

Liver

STRUCTURE Blood

LOCATION

FUNCTION Carries oxygen from the lungs to all the other tissues in the body and, in turn, carries waste products, predominantly carbon dioxide, back to the lungs where they are released into the air. Their primary function is to carry oxygen from the lungs to every cell in the body. Red blood cells are composed predominantly of a protein and iron compound, called hemoglobin, that captures oxygen molecules as the blood moves through the lungs, giving blood its red color. They play a vital role in the bodys immune systemthe primary defense mechanism against invading bacteria, viruses, fungi, and parasites. They often accomplish this goal through direct attack, which usually involves identifying the invading organism as foreign, attaching to it, and then destroying it. Constricting the blood vessels to

Red Blood Cells

White Blood Cells

Platelets

Blood Vessels Veins

reduce bleeding, attracting more platelets to the area to enlarge the platelet plug, and initiating the work of plasma-based clotting factors, such as fibrinogen. Transports blood through the body. One of the tubular vessels that conveys blood to the heart from the tisssues of the body. One of the tubular vessels that conveys blood from the heart to the tissues of the body. One of the minute blood vessels that form the connection between the arteries and the veins. Found in the hallow interior of the Bone marrow is the spongy tissue bone inside some of your bones. It contains immature cells, called stem cells. It is located at the right upper quadrant The liver manufactures most of the of the abdomen, on the right side of clotting factors that the body uses to the body just below the diaphragma stop bleeding. The time it takes to sheet of muscle tissue that separates produce a clot, called the the lungs from the abdominal organs. prothrombin time (PT), generally runs from nine to eleven seconds. Vitamin K is an important factor in the blood clotting process. If the liver is a very seriously damaged or if a

Artery

Capillary

Bone Marrow

Liver

vitamin K deficiency is present, the PT will run much longer than normal, thereby increasing the risk of excessive bleeding. In some cases, injections of vitamin K can help the PT return to normal. Improvement of the PT with a vitamin K injection indicates that the liver is still functioning. When the PT does not normalize after a vitamin K injection, a condition known as a coagulopathy (a tendency to bleed excessively), severe liver damage, and/or liver failure may exist.

V. Pathophysiology
Predisposing factors: Age:0-15 years old Geographical area -tropical and subtropical areas like Philippines is particularly at risk

Precipitating Factors: Environmental conditions Mosquito carrying dengue virus Daily Activities (playing near the mosquito breeding sites)

Aedes Aegypti (dengue virus carrier): 8-12 days of viral replication on mosquitoes salivary glands

Bite from mosquito (Portal of Entry in the Skin)

Redness and itchiness in the area

Allowing dengue virus to be inoculated towards the circulation /blood (Incubation Period: 3-14 days)

Virus dessiminated rapidly into the blood and stimulates WBCs including B lymphocyte that produces antibodies and monocytes/macrophages, neutrophils

Anti bodies attach to the viral antigens, and then monocytes/ macrophages will perform phagocytosis and dengue virus replicates in the cells of monocytes/ macrophages

Recognition of Dengue viral antigen on infected monocytes by cytotoxic T cells

Release of cytokines which stimulates WBCs and pyrogen release

Cellular direct distruction and infection of red bone marrow

Thrombocytopenia

Diagnostic CBC Decreased Platelet 123 000/cumm (150 000- 400 000)

Bursting of capillaries

Signs and symptoms manifested by the patient petechiae (Hermans rash) body weakness sudden onset of fever (39C)

Dengue

Signs and symptoms: (39C-41C), headache generalized body pain body weakness rashes nausea vomiting

If treated: It will not lead to other more serious complications

If not treated: It will lead to more severe condition

Dengue Hemorrhagic fever Signs and symptoms: Hemorrhagic manifestations such as: petechiae, subconjunctival bleeding, gum bleeding, gastrointestinal hemorrhage, hepatomegaly circulatory failure

Dengue shock syndrome Collapse of blood vessels

Death

The predisposing factors, which contributed to the development of the disease, are the following: First, the geographical area. It has something to do with the acquisition of the disease since Dengue Virus is a viral disease found in most tropical and subtropical areas. Philippines is one of the country which is particularly at risk. The age is also one of the factors. Dengue fever affects people regardless of age group but majority of the cases are among children 0-15 years old. The clients age is 11 and it is within the age bracket in which most number of Dengue fever cases are recorded. On the other hand the precipitating factors are the following: The patient possibly acquired the disease from the school since there were no mosquito breeding sites around their home. She was enrolled in a public school where there is a high population of students. The patient is also prone with the disease because she loves to play at the school playground where there are mosquito-breeding sites like stagnant water. A female mosquito Aedes Aegypti, a dengue virus carrier, bit the patient. After an extrinsic incubation period of 8-10 days, the salivary glands of the mosquito became infected and the virus is transmitted when the infective mosquito bites and injects the salivary fluid into another person. Following an incubation period in humans of 3-14 days, there will be sudden onset of the disease, with fever, headache and other non-specific signs and symptoms including nausea, vomiting and rash. The virus disseminated rapidly into the blood and stimulates WBC and B-lymphocytes (which is responsible for the production of anti bodies) and monocytes, macrophages, and neutrophils (which injects and kills foreign microorganisms). Anti bodies attach to the viral antigens, and then the monocytes/macrophages will perform phagocytosis (engulfment of foreign particles by a cell). Dengue virus replicates in the cells of monocytes/macrophages. The cytotoxic T cell (a type of T lymphocyte that destroy virus infected cell) will recognize the dengue viral antigen on infected monocyte. Then, the cell will release cytokines (which are involved in cell to cell communication, acting an enhancing mediators for

immune responses through interaction with specific cell- surface receptor on leukocytes), which stimulates WBC. There will be direct destruction and infection of red bone marrow. Dengue virus, which induces bone marrow depression, may be the cause of low platelet count or thrombocytopenia. Platelets are responsible for the arrest or blood coagulation. Since capillaries are extremely narrow, they will burst because of continuous bleeding, which results to petechiae (Hermans rash). The signs and symptoms of dengue are fever (39C - 41C), headache, generalized body pain, body weakness, rashes, nausea and vomiting. The patient manifests the signs and symptoms of dengue fever such as petechiae (Hermans rash), body weakness and sudden onset of fever (39C). Abdominal pain was also experienced but on the case of our patient, the experienced pain was due to UTI. If treated, it will not lead to other more serious complications. On the other hand, if it is not treated, it may lead to a more serious one which is DHF (Dengue Hemorrhagic Fever). In DHF, there will be hemorrhagic manifestations such as petechiae, subconjunctival bleeding, gum bleeding, gastrointestinal hemorrhage, hepatomegaly and circulatory failure. Without prompt treatment, it may cause the blood vessels to collapse, which is called the Dengue Shock Syndrome leading to death.

VI. Laboratory and Diagnostic Procedures March 12, 2010 Urinalysis Urinalysis is a physical, chemical, and microscopic analysis of the urine. It is useful for diagnosing renal disease or urinary tract infection and for detecting metabolic disease not related to the kidney. The color, appearance, and odor of the urine are examined, and the pH, protein, glucose ketones, and bilirubin are tested with the reagent strips. Specific gravity is measured with a urinometer, and a microscopic examination of the urinary sediment is performed to detect red and white blood cells (RBCs, WBCs) casts, crystals, and bacteria.

Urinalysis Color

Reference Values Straw to Light amber

Actual Result Dark Yellow

Interpretation Normal Color change due to decreased intake of water

Transparency

Clear

Slightly Turbid

Cloudy urine may indicate presence of pus (WBCs), RBCs, or bacteria due to urinary tract infection Positive indicator of urinary tract infection Normal

Albumin Sugar

Negative(-) Negative(-)

Positive(+) Negative(-)

March 12-16, 2010 Complete Blood Count (CBC) This test is done to provide data for the blood content of the patent. It assesses the overall hemostatic function of the blood. CBC Referenc e Values Actual Result
(March 12,2010)

Actual Result
(March 13,2010)

Actual Result
(March 14,2010)

Actual Result
(March 15,2010)

Actual Result
(March 16,2010)

Interpretatio n

Hematocr it

F: 35 46 vol.%

38 vol. %

33.2 vol. %

33.0 vol. %

32.4 vol. %

33.8 vol.%

March 12, 2010 Normal March 13-16, 2010 Decreased Below normal range is an indication of blood loss, Vitamins

deficiency (Vitamin C). Vitamin C increases the absorption of Hemoglo bin F: 12-16 g/dl 11.1 g/dl 10.8 g/dl 11.0 g/dl 10.7 g/dl 10.6 g/dl Due to poor oxygen WBC Count 5,00010,000/c umm 4,600/ cumm 3,200/ cumm 4,800/ cumm 6,950/ cumm 10,000/ cumm supply March 15-16, 2010 Normal March 12-14, 2010 Decreased iron. Decreased

Pseudoleuko penia develops an infection. The leukocytes (predominatel y neutrophils, responding to injury first) are marginalized in the blood vessels so that they can scan for the site of

infection. This means that even though there is increased WBC production, it will appear low from a blood and does not include the marginalized Platelet count 150,00400,000/ cumm 126,000/ cumm 123,000/ cumm 116,000/ cumm 134,000/ cumm 159,00 0/ cumm leukocytes. March 16, 2010

Normal March 12-15, 2010 Decreased Decreased platelet production is an indicative of a bone marrow MCV 80-97fl 63.9 fl 64.4 fl 63.2 fl 65.0 fl problem. Decreased Values less than 80fl may indicate iron

deficiency

RBC Lymphoc yte

4.206.30m/ul 20-40%

5.88 m/ul 18%

5.14 m/ul 27%

57%

5.13 m/ul 39.7%

5.20 m/ul 48.2%

Normal March 13 & 15, 2010 Normal March 14 & 16, 2010 Increased An increase in lymphocyte concentration is usually a sign of a viral

infection. March 12, 2010 Decreased A decrease in lymphocyte may lead to very high risk of infection, particularly RDW 11.5-15.5 16.4 16.7 16.7 viral infection. March 12, 14 & 16, 2010 Increased Increased

RDW indicates mixed population of RBCs; immature RBCs tend to RBC count PT time 4.66.0x1012L 10-13 sec. 5.14 x1012L 5.13 x1012L 13.2 sec. 5.20 x1012L be larger. Normal Normal

MARCH 12, 2010 TYPHIDOT

It is for the rapid detection of specific IgM and IgG antibodies against a specific antigen for Salmonella typhi. Test igG igM March 15, 2010 Urine Culture and Sensitivity This test is done to find and identify germs, usually bacteria that may be causing a Urinary Tract Infection. A urine culture is a method to grow and identify bacteria that may be in the urine. The sensitivity test helps caregivers pick the best medicine to treat the disease. Result: No growth after two days of incubation. Actual Result Negative (-) Negative (-) Interpretation Normal Normal

VII. Medical Management

Medical Regimen Day 1 March 12, 2010

Drug

Rationale
Classification Indications Adverse Effects Nursing Responsibility

To provide medical management and monitor the Please admit to ROC under the service of Dr. and And Or condition of the patient. Romualdo Reyes. Secure consent for admission and care.
Mechanism of Action Contraindications

It serves as a legal documentation.

Side Effects

Generic Name: avoid dark colored foods Classification: DAT, Ranitidine Drugs Monitor vital signs Receptorrecord Brand Name: (H2 q4 and Zantac Stock: ampule Gastrointestinal

Indications:

xis of GI hemorrhage.

It alters the result of Cardiac CNS: stool examination. Monitor GI Dark colored foods may mask bleeding. In dengue fever, there could discomfort. Hyperacidity.Prophyla arrhythmias be internal bleeding which can be seen in the patients vomitus and stool.
Avoid antacids for 1 hour before taking It serves as a baseline data. TPR and BP are monitored Headache of dengue fever. drug. to watch out for the severity Fatigue Bradycardia

BP q2

antagonist)

Contraindication:

To assess the severity of the disease. In dengue fever Advise to take with bleeding Hypersensitivity to might occur. Ifvision Blurred excessive bleeding happens, it meals. reflects to the BP of the patient. The BP may decrease. It is a hypertonic solution that pulls fluid out of the cells for Assess patient Hallucinations into the intravascular space. It is also a abdominal pain. Note nonpyrogenic solution for fluid and electrolyte replenishment of blood in presence and Depression caloric supply in a single dose container for IV emesis, stool, or administration. It is needed to keep systolic aspirate. gastric blood Insomia pressure above 90mmHg.It may also be necessary for hypotension.
Ranitidine may be added to and CBC To determine hemoglobin, hematocrit, total Rash parenteral nutrition erythrocyte, or red blood cell (RBC) count, and assess solutions. the bloods ability to multiforme Erythema carry oxygen; to determine the Alopecia Dizziness

drug. 35mg

IVF D5LR 1L x 120cc/hr

/ Mechanism Action:

of

Inhibits Histamine Doctors order: at H2 receptor site in

Ranitidine the gastric parietal Diagnostic: CBC and U/A done outside 35mg IV q8 cell, which inhibits

gastric acid secretion.

leukocyte, or white blood cell (WBC) count, which signals infection when elevated. U/A To detect urinary tract infections and glucose in the urine.

Repeat CBC, Platelet tomorrow am

Platelet to monitor aggravation or improvement on the clotting factor of the patient. AggravationAssesslead to may knowledge/teach hemorrhage. A decrease in circulating platelets of less patient appropriate than 50% of the normal value will cause bleeding, if the GI:Nausea use, possible effects/ decrease is severe (less than 50,000ul), hemorrhaging appropriate might occur. Vomiting interventions, and To assess change in status. The result is beyond the adverse symptoms Abdominal discomfort normal range. The procedure is repeated to determine if to report.

Drug

Classification and Mechanism of Action

Indications And Contraindications

Adverse Effects Or Side Effects

Nursing Responsibility

Generic Name: Paracetamol

Classification: Anti-pyretic

Indications: Treatment of fever.

Brand Name: Tempra Forte

Mechanism Action:

of

Contraindication:

Drowsiness Nausea Vomiting Allergic skin reactions Abdominal pain Urticaria Cyanosis
Anemia

Assess patients fever or pain: type of pain, location, intensity, duration, temperature, and diaphoresis. Assess allergic reactions: rash, urticaria. Instruct patients mother to avoid giving more than one product containing paracetamol (acetaminophen) at one time, as this may cause toxicity. Teach the patients mother to recognize signs of chronic overdose: bleeding, bruishing, malaise, fever and sore throat.

Decreases body Stock: 325 mg / tab temperature by

Hypersensitivity Anemia Cardiac and pulmonary disease

Hepatic and severe renal disease.

inhibiting the effect of pyrogens on the heat

Doctors order: Paracetamol 325

hypothalamic

regulating centers and by a hypothalamic leading to and

mg 1 tab prn with fever

action sweating

vasodilatation.

Drug

Classification and Mechanism of Action

Indications And Contraindications Indications: Effective mostly organism against gram(-) such as

Adverse Effects Or Side Effects Shock Granulocytopenia or eosinophilia Anaphylactoid symptoms StevenJohnson syndrome Lyells syndrome

Nursing Responsibility

Generic Name: Cefixime

Classification: Anti-infectives (Cephalosporins 3rd

Brand Name: Tergecef

Generation)

Pseudomonas Mechanism of Action: aeruginosa.

Stock: 10 mg / cap

Inhibits bacterial cell wall rendering synthesis cell wall Contraindication: Hypersensitivity to cephalosphorin or

Hematologic disorder Acute renal failure Pseudomembranous colitis Interstitial pneumonia or Pulmonary Interstitial Emphysema syndrome Increase in GOT, GPT or alkaline phosphatase GI disturbances

Doctors order: Tergecef 10 mg 1 cap q12

osmotically

unstable,

leading to cell death.

penicillin. Caution with bleeding disorders, or GI distress, and renal or hepatic impairment.

Monitor vital signs, I&O, and undesirable effects. Assess patients previous sensitivity reaction to penicillin and cephalosporins. Crosssensitivity between penicillins and cephalosporins is common. Administer on an empty stomach for better results. May take with food if gastric irritation develops Assess for the allergic reaction and anaphylaxis: Rash, urticaria, pruritus, chills, fever and joint pain. Asses for the Renal function before and during the theraphy: urine output.

Drug

Classification and Mechanism of Action

Indications And Contraindications Indications: / To increase body resistance against

Adverse Effects Or Side Effects Adverse Effect: Drowsiness Dry mouth Headache Nausea Hallucination Constipation

Nursing Responsibility

Generic Name: Multivitamins + Lysine

Classification: Multivitamins Vitamin Supplement

Assessment:

disease or infections; Brand Name: Bevon C Mechanism of Action: For the growth and repair of tissues in all Dosage: 500mg/ tab parts of your body. for nutritional support, general weakness vitamin supplementation. and body daily

Assess for Vitamin C deficiency before and during the treatment. Monitor Intake and Output ratio; polyuria; in patients receiving large amount doses renal stone may occur Assess the patients and Familys knowledge on drug therapy. Do not crush, break, or chew extended release tablet/capsule.

L-Lysine

Contraindication:

Hydrochloride 12.5 mg

Hypersensitivity to the drugs

Doctors Order: Bevon 500mg/tab OD C

Drug

Classification and Mechanism of Action

Indications And Contraindications

Adverse Effects Or Side Effects

Nursing Responsibility

Generic Name: Loratadine Brand Name: Lorid Dosage: 10 mg / tab Doctors Order Lorid 10 mg 1 tab once a day

Classification: Antihistamine

Indications: Anaphylactic reaction, acute of urticaria, and motion sickness. at H1 Contraindication: Hypersensitivity. Caution with allergies. Loratadine should be used with caution disease reduction necessary impairment. in and may in hepatic dose be renal

Adverse Effect: Fatigue Dizziness Nausea Dry mouth Headache CNS depression Psychomotor impairment Thickened Respiratory tract secretion Urinary difficulty or retention Constipation Increase gastric reflux

Assessment: Assess the patients condition (respiratory status: rate, rhythm, increase in bronchial secretions, wheezing, chest tightness) before therapy and regularly thereafter the monitor effectiveness. Monitor any adverse effect Assess patients and familys knowledge of drug therapy Give on empty stomach, 1hr before or 2hrs after meal to facilitate absorption. Store the drugs in airtight, light-resistant container

Mechanism Action:

Competes with histamine peripheral histamine to reduce and prevent

receptors and increase

capillary permeability bronchospasm without sedation.

IX. Nursing Care Plan 1. Assessment Nursing Diagnosis Acute pain related to Gastrointesti nal irritation as manifested by epigastric pain scale=4/10 Case Background Eating small amounts of food Secretion of gastric acid Hyperacidity of stomach Irritation Nerve endings signal the spinothalamic tract Transmit impulses to the Plan Goal: To relieve pain Interventions Independent: Monitor vital signs Rationale

Subjective Cues: Sumasakit ang tiyan ng anak ko, as verbalized by the patients father.

Objective Cues: Facial grimace Epigastric pain - Pain scale of 4 / 10 Guarding

Objectives: After 8 hours of nursing intervention, the client will: 1. Verbalize pain is decreased from Perform pain 4/10 to 1/10 assessment each time 2. Verbalize the pain occurs. method that provide relief such as back rubbing 3. Follow Assess for possible prescribed referred pain pharmacologic

To obtain baseline data; vital signs usually altered in acute pain vital signs usual increases when pain increases To rule out worsening of underlying condition because this may be an indication of internal bleeding To help determine possibility of underlying condition or organ dysfunction requiring treatment

behavior

brain to sense pain Acute pain (epigastric pain)

al regimen such as taking analgesic

Promotes relaxation that lessens stress and pain Provide quiet and clean To provide non environment pharmacological pain management that lessens the pain because the brain Provide comfort recognizes more the measures such as back rubbing rather than the rub, changing of pain position, etc. These are methods for control of pain.

Encourage use of relaxation exercises like focused breathing

Dependent: Administer analgesic (Ranitidine)

Inhibits histamine at H2 receptor site in the gastric parietal cells which inhibits gastric acid secretion Citrus and spicy foods may stimulate the GIT to increase

production of hydrochloric acid. Collaborative Refer to dietician for proper foods to eat; citrus and spicy foods will not be advised to eat

2. Assessment

Nursing Diagnosis

Case Backgro und Decreas ed platelet count Bursting of capillarie s Herman s rash Histamin e activatio n Pruritus

Plan

Interventions

Rationale

Evaluation

Subjective Cues: Makati daw yung mga rashes niya. As verbalized by the patients father. Objective Cues: Pruritus at the lower extremiti es Petechia l rash at

Impaired skin integrity related to bursting of capillaries secondar y to thromboc ytopenia as manifeste d by petechial rash and pruritus

Goal: Independent: To restore Assess patients optimum skin skin integrity integrity Objectives: After 8 hours of nursing interventions the Keep the area client will: clean and dry 1. Eliminate itchiness on the lower extremity 2. Recognize different ways to attain Limit or avoid enhanced use of plastic skin integrity material. Remove wet or wrinkled linens

Partially Met To assess underlying skin condition; this will serve as baseline data After 8 hours of nursing intervention, the patient experienced diminishing rashes on the patient at the lower and upper extremities, and absence of pruritus at the lower extremities.

To assist bodys natural process of repair; clean and dry environment has less microorganism that may affect patients condition Moisture potentiates skin

the upper and lower extremiti es Redness of the skin at the lower and upper extremiti es Dry skin Dry lips Platelet count = 123,000 cumm

Impaired Skin Integrity

promptly. Maintain good skin hygiene such as washing hand thoroughly and patting dry carefully.

breakdown; plastics are prone to moistures Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma of dry skin Long nails increases risk of dermal damage Prevent direct skin irritation and promote evaporation of moisture on skin Improved nutrition and

Encourage client to maintain short nails Suggest wearing of the loosefitting cotton garments

Emphasize importance of adequate nutrition/fluid intake

 Advice use of lotion with mosquito repellant Dependent: Administer prescribed antihistamine (Lorid)

hydration will improve skin condition; Vitamin C and vitamin D contain antioxidants that assist in improvement of skin status Lotion makes the skin smooth and hydrated

Collaborative:

Lorid competes with histamine at peripheral H1 histamine receptors to prevent or reduce increase capillary permeability and bronchospasm without

 Refer patient to dermatologist for more teachings about skin care

sedation

Enhances knowledge about skin improvement

3. Assessment

Nursing Diagnosis

Case Backgro und Dengue Fever Destructi on of platelets Low platelet Fatigue Muscle weaknes s Prolonge d Lying position

Plan

Interventions

Rationale

Evaluation

Subjective Cues: Hindi siya nakakakain ng mag-isa kasi nahihilo siya. Hindi din siya makatayo ng mag-isa. As verbalized by the patients father.

Objective Cues: Spoon-fed and bathed by

Self-care deficit related to current situation: dizziness as manifeste d by bathing, eating, toileting, and maintaini ng appearan ce at satisfacto ry level with

Goal: Independent: To enhance self- Monitor and care of the record vital patient signs Objectives: After 8 hours of nursing interventions the Identify the client will: contributing 1. Eat and bathe problems that without may be factors assistance for care 2. Tolerate activities that involves dressing and Instruct the client to limit combing physical activity

To obtain baseline data and assess the change in the blood pressure because f changing of position

Goal Met After 8 hours of nursing intervention, patient is able to eat and bathe without assistance and tolerate activities as evidenced by dressing and combing on her own.

To know the causative factors such as dengue fever

Activity and stress may

the mother Assisted in going to the toilet Irritable weak

assistanc e

Abrupt changing in position Orthostat ic hypotens ion Dizzines s Inability to perform activities like eating, bathing, and toileting alone SelfCare deficit

Encourage the patient to increase water intake

contribute to heat production that may increase the intensity of dizziness

Instruct the patient to avoid abrupt changing of position such as lying to standing and from sitting to standing if dizziness is lessen Encourage the patient to eat, bath and go to toilet alone Encourage to dress appropriately

To replenish electrolytes in the body

It may cause orthostatic hypotension.

 To enhance the ability of the patient to have Advise patient to self care use lotion and to comb her hair To have good Maintain good grooming skin hygiene such as washing hand thoroughly Dependent: Administer or monitor medical regimen and note clients response such as anti-vertigo drugs.

It moisturize and hydrate the skin Maintaining clean, dry skin provides a barrier of infection To determine the effectiveness of therapy and presence of side effects

4. Assessment

Nursing Diagnosis

Case Backgro und Dengue Fever Destructi on of platelets Low platelet count Bleeding Low blood pressure Prolonge d lying in bed

Plan

Interventions

Rationale

Evaluation

Subjective Cues: Nahihilo ako. As verbalized by the patient.

Risk for fall related to current situation: dizziness

Goal: Independent: To eliminate risk Raise the side for fall rails. Objectives: After 8 hours of nursing Advise patient to interventions the lie on the other client will: side of the bed which is 1. Demonstrate attached to the proper wall positioning such Advise to have as lying, sitting adequate rest and standing and sleep. 2. Enhance safety by maintaining the Advise patient to side rails on the avoid abrupt bed side that will changing of eliminate position such as

Side rails are raised to prevent patient from falls especially during sleeping. Lying on the safer side will eliminate/reduc e chances for falling Adequate rest and sleep will reduce / eliminate dizziness May cause orthostatic

Goal met After 8 hours of nursing intervention, the patient is able to eat and bathe without assistance and tolerate activities as evidenced by dressing and combing on her own.

Objective Cues: Patients bed has no side rails Patients lying on the edge of the bed

Change in position Orthostat ic hypotens ion Dizzines s Risk fall for

chances for fracture, bruises, etc.

turning to other side, standing or sitting Demonstrate dangling of legs

hypotension that may cause injury or fall

Dangling of legs will reduce chances for orthostatic hypotension

X. Summary of Discharge M - Lorid 10 mg 1 tab, once a day, until March 21, every 8 in the morning. Tergecef 100 mg 1 cap , every 12 hours fro 7 day, during 8am and 8 pm. E - Provide a clean, safe and quiet environment to avoid spreading of virus. - Avoid canals, roofs and places where stagnant water is present T - Supportive treatment like intravenous fluid replacement, it is required to prevent shock in patient H Recommended observing the proper hygiene especially in cleaning the genital organs because it prevents further infection. -Slightly cover all the containers to prevent the breeding areas of the mosquitoes. -Avoid aspirin because it decreases the platelets. -Advised the use of mosquito repellant lotions because it can inhibit the mosquito from coming -Advised to increase oral fluid intake to decrease dehydration -Discard items that can collect rain or run of water, especially old tires because mosquito larvas grows in stagnant water then later on will become a mosquito to spread the infection from a dirty water -Avoid heavily populated residential areas because a person who has weak immune system can easily acquire disease -When outdoors during times that mosquitoes are biting, where thick long sleeved shirts and long pants tucked into socks because it can prevent from bitten by mosquitoes -When indoor, stay in air-conditioned or screened areas. Use bed nets if sleeping areas are not screened or airconditioned for protection from mosquitoes

O Inform the client to return after 1 week, March 23, 2010 at OPD D Advise to take foods rich in Vitamin K (Lettuce, Okra, Onion), Vitamin C (Guava, Carrots, Apples), Iron (Green Leafy Vegetables, such as kangkong). -Eat also malunggay because it is rich in vitamin C 7x than orange, calcium 4x than milk, and Potassium 3x than banana. -Avoid carbonated drinks and junk foods because it can develop or worsen the infection S Pray and always ask the guidance of the Lord. -Have faith in God. -Read religious articles