INTRODUCTION

The bodys overall health is important, to be able to do things, we have to be physically fit, to be able to make good choices for our future, we need to be mentally robust and to be able to survive the woes of humanity, we should be emotionally prepared. To achieve things, we need to stay healthy. Being fit and ready is a basic principle of nature; to survive we must be healthy. Unfortunately, there are circumstances that we cannot foresee and disease is experienced, the body tries to cope and if it is unable to combat the condition, death may ensue. Of course, that situation is lessened by the fact that we now have several advanced treatments for different diseases experienced by the body. One disease that has brought fear among our tropical country, the Philippines, is dengue hemorrhagic fever. It is a viral disease that is transmitted through the Aedes Aegypti mosquito and is potentially deadly if not treated properly. A potentially lethal complication of this disease is the dengue hemorrhagic fever which mostly occurs in children. According to WHO, 2.5 billion people or about two fifths of the worlds population are at risk for dengue, mainly their homes are near habitats of the mosquito. The organization estimates that about 50 million people may have dengue infections worldwide every year. In the year 2007, around 890,000 dengue cases were reported in America and around 26,000 of those cases were already dengue hemorrhagic fever. Fatality rates of DHF can exceed 20%, however, because there is now wider access to medical care, proper diagnosis and management can lower the fatality rate to less than 1%. In the year 2010, The Philippines has at least 5 dengue victims who are dead from January to June. In addition, more than 500 have been confined at different hospitals in the country particularly in Cagayan De Oro city which is one of the highest numbers of cases. Statistics shows that the cases increased by 200 this year. In Davao City, it has the highest recorded Dengue cases in the country. Statistics shows that there are more than 892 cases recorded from January to May this year affecting mostly children aged six to 15 years old and a total of 5 individuals died just recently. Moreover, there were 649 dengue cases recorded for the same five-month period last year but 24 of the patients had died. The mosquito usually bites between 6-8 in the morning and 4-6 in the afternoon.

While the group were having our exposure in Davao Medical Foundation Incorporated, Davao City, we were able to handle several dengue cases. Being curious, we selected a patient, whom we shall call Patient X, diagnosed with dengue hemorrhagic fever I. The group chose this case because dengue is a feared and potentially fatal disease. It may become more common due to the unstable weather conditions our country is experiencing and we would like to learn about it more thoroughly. Hopefully, this case study will give us the knowledge on dengue hemorrhagic fever and allow us to give good quality of nursing care in the future. The gathered information from the patient and her significant others will serve as a basic framework for this case study. We hope to enhance our skills in promoting the art of care and wellness in every patient we encounter. The study would be relevant to the client as it will help us student nurses understand and properly intervene. With this study, we hope the patient will be properly assisted in achieving a rewarding experience of recovery and health.

ACKNOWLEDGEMENT
In the course of this study, the proponents have encountered different obstacles in which patience, perseverance, courage and determination were needed in order to finish an organized and comprehensive case study. We, the proponents would like to thank the following persons for their ideas, time and support in the realization of this case study. To our beloved Holy Father, for giving us wisdom, knowledge, protection and the skills required of us to become an effective student nurse. We give thanks to the blessings He has given us to finish this case study. To the Patient X and her family whom have allowed us to conduct this case study. We thank them for their cooperation during the interview. Their support and patience are highly appreciated. To our beloved families who have given us their complete support understanding throughout the course of the study. To the Davao Medical School Foundation College of Nursing for providing us with the skills to give proper quality care to our patients in the hospital exposures and for providing us with knowledge to conduct and make this case study a success To Staff of the Pedia Ward at Davao Medical Center St. Michael pediatric ward for welcoming and accommodating us with open arms as we were given the chance to expose ourselves to the setting and patients. To the Davao Medical School Foundation Clinical Instructors, especially to Ms. Kristina Concepcion, who has given her untiring patience, guidance and supervision throughout the exposure and case study. And lastly, to the people who have helped us finishing this case study we give our sincere and whole hearted gratitude to you. Thank you!

OBJECTIVES
General Objectives:

Within our 5 days exposure at the Pedia ward of Davao Medical School Foundation Hospital Incorporated, the group will be able to gain more knowledge about the condition of our chosen client and apply the knowledge learned in class to the clinical setting. Most importantly, after the exposure, the group will be able to present an organized and comprehensive study on the patients diagnosis, Dengue Hemorrhagic Fever I,

Specific Objectives: Furthermore, the proponents would like:

To present the data gathered from the interview conducted with the patient and

significant others;
to identify the patients medical diagnosis in order to know what ailment our patient has

experienced;
to conduct a thorough cephalocaudal physical assessment on the patient as a component

for baseline data;

to apply the different theories of growth and development in relation to the patient so as

to assess the patients ability to achieve essential tasks in various developmental theories;
to discuss the anatomy and physiology of the specific body systems involved in the

disease process;
to cite the etiology and symptomatology of the disease in relation to the patient;

to trace the pathophysiology of the disease in order to determine the mechanism of the disease process. to study the drugs prescribed to the patient to gain knowledge regarding the medications prescribed. to present different nursing theories that are applicable and related to the patients situation. To present nursing care plans formulated and rendered to the patient during the groups clinical exposure.
to deliver the groups recommendations.

 to create and present the prognosis of the patients condition. to provide appropriate health teachings to the client and her significant others in achieving optimum wellness. to properly present all the sources of the groups research, and arrange them in a bibliography to prevent plagiarism.

PATIENTS PROFILE
Age: 7 years old Sex: Female Birth Date: August 18, 2002 Birth Place: Davao City Address: Batalla Village Catalunan Pequeno, Davao City Nationality: Filipino Religion: Roman Catholic Civil Status: Single Fathers Name: Mr. X Mothers Name: Mrs. X Educational Attainment: College Graduate Occupation: GMA Crew Room/Bed #: Room 329 Bed 1 Date of Admission: July 20, 2010 Time of Admission: 04:20 PM Hospital: Davao Medical School Foundation Incorporated Ward: St. Michael Pediatric ward Attending Physician: Evelyn Capilitan, M.D. Chief Complaint: Came in due to fever Admitting Diagnosis: Fever Final Diagnosis: Dengue Hemorrhagic Fever Source of Information: Patient; Significant others and patients chart

FAMILY BACKGROUND Patient X was born via normal spontaneous vaginal delivery last August 18, 2002 at Davao Medical Center. Shes the eldest daughter. She lived with her family at Batalla Village Catalunan Paqueno Davao City. At present she is a grade 1 pupil and her parents were both professionals who support her financial needs. Patient X father stated that their house is concrete and with proper light and ventilation. Though they have a faucet as their main source of water they also usually stored water for emergency purposes. Patient X father also notice about their open drainage that made the water became stagnant as claimed. Past Medical History Patient X mother claimed that Patient X has been fully immunized at the age of 12 months old at their local Health Center. As her mother claimed that this was her 1st hospitalization though she experienced fever, colds and cough during her childhood years and home medications were given such as paracetamol, mefenamic acid and some traditional medication. Life Style Patient X was a student she sleeps at 8pm at night and usually sleep at 5:30am. She spent most of her time at day in school. She was capable of wearing her cloths and doing some hygienic practices like bathing, cutting her nails and oral care. She claimed that shes fun eating junks foods like pewee and riche and rarely eats vegetables. She love to play with her friend at their nieghbors backyard after the school and usually goes home at 6pm . History of Present Illness 2 days prior to admission she had an intermittent fever and medication was given such as paracetamol, fever subsided; no consultation was done; 1 day prior to admission fever persisted medication was given; fever not subsided; medical consultation done and advised to be admitted.

PHYSICAL ASSESSMENT General Appearance: Patient X was awake, conscious, coherent and responsive; appeared weak. Wears a proper grooming and have a proper hygiene without body odors. She can do fine and motor movements without any pain and discomfort. Shes able to ambulate around the unit without any assistance with a good gait. Skin She has a Filipino brown colored skin. No skin disloration noted. No lesions and open would noted. Rashes was noted at left and right inner thigh. Skin is dry and warm to touch no palpable nodules or lumps noted. With good skin turgor. Hair is evenly distributed all over the body. Nails were properly trimmed. Head Head is normocephalic with symmetric facial structure. Hair was straight and evenly distributed all over the scalp. No dandruff noted or any parasites. Eyes and Vision Eyes were symmetric with equal distribution of eyebrows. With clear sclera pupil has the ability to constrict when exposed to light at 2-3mm. Blink reflex is present. Patient can identify far and near objects and can read written words without any difficulties as claimed. No know history of blured vision. Ears and Hearing Ear has same color as facial skin. Auricles were symmetric. Pinna able to recoil after being folded. No signs of inflammation on outer ear noted. Minimal cerumen noted at the inner ear. Able to hear whispered words at this distance of 12 centimeter. Able to hear normal voice clearly.

Nose Patient Xs nose is symmetrical having the same color with her face. Septum is intact and located at the midline with no discharges, lesions and abnormal growth in the nasal cavity noted. Air moves freely through the nares as she breaths. Patient X reported that he is able to distinguish different kinds of scents. Mouth (Teeth, tongue, Lips) Dental caries noted at left lower molars; teeth were pearly white in color. Missing tooth noted. Tongue is located at the midline and slightly moist. Patient able to move her tongue freely. No signs of inflammation noted. Lips were symmetric pink in color and slightly moist. Neck Neck of Patient has no signs of swelling, masses and lacerations noticed in the anterior and posterior of the neck upon inspection and palpation. Range of motion is normal which includes right and left lateral, right and left rotation, flexion, extension and hyperextension and able to move freely with minimal hesitancy. Carotid arteries are palpable on both side. Chest and Thorax Thorax and nipples are symmetrical with no swelling noted upon inspection. With equal lung expansion during respiration. The breathing pattern is regular. No presence of dyspnea, cough or hiccup. Resonant sound can be heared during percussion. Dull sound is percussion at the right 11th rib. Abdomen The general contour of Patient Xs abdomen is normal and flat. With symmetric color. Has bowel sound of 8 per minute with a gurgling sound. Tympanic sound can be heard during percussion at four quadrants. Abdomen not distended. heared during

Genitourinary Patient able to void freely without any pain and discomfort. Latest 24 urine hour output was 1300 liter, yellowish in color. Circulatory Patient was not cyanotic. Peripheral pulses were palpable on both sides. Point of maximal impulse can be heared at 5th intercostal space. Blood pressure of 110/60 mmhg. Capillary refill time of 2-3 seconds. No signs of active bleeding observed.

DEVELOPMENTAL DATA
Human development is a process of enlarging peoples choices. Enlarging peoples choices is achieved by expanding human capabilities and functioning. At all levels of development the three essential capabilities for human development are for people to lead long and healthy lives, to be knowledgeable and to have access to the resources needed for a decent standard of living. If these basic capabilities are not achieved, many choices are simply not available and many opportunities remain inaccessible. But the realm of human development goes further: essential areas of choice, highly valued by people, range from political, economic and social opportunities for being creative and productive to enjoying self-respect, empowerment and a sense of belonging to a community. Psychosocial Theory of Development by Erik Erikson Erik H. Erikson believes that people continue to develop throughout life. He described eight stages of development. He envisions life as a sequence of levels of achievement. Each stage signals a task that must be achieved. The resolution of the task can be complete, partial or unsuccessful. Erikson believes that the greater the task achievement, the healthier the personality of the person. Dev. tasks can be viewed as a series of crises, and successful resolution of these The patient is 7years old. She belongs to the stage of school age (6-12 years old). This is the industry versus inferiority stage. During this stage, often called Latency, the individual is capable of learning, creating and accomplishing numerous new skills and knowledge, thus developing a sense of industry. This is also a very social stage of development and if we experience unresolved feelings of inadequacy and inferiority among our peers, you can have serious problems in terms of competence and self esteem. As the world expands a bit, the most significant relationship is with the Patient X is in this stage, industry versus inferiority, since she is 7 years old. She was able to learn new skills and knowledge needed on her everyday life provided by the help of her parents and her teachers at school. She also promotes social interaction towards her peers at school and at home especially during play times. Her mother verbalized that she has no problems at school regarding misdemeanor or misconduct.

crises is supportive school and to the persons ego. neighborhood. Parents are no longer the complete authorities they once were, although they are still important.

Robert Havigh urst

Developmental task Theory, based on learning and learned behaviors, called developmental tasks that emanate from biologic, psychological and social origins during life span. Specific developmental tasks are assigned to various stages of life. Failure to complete the tasks assigned to each stage may lead to failure in tasks in subsequent stages. According to this theory, success in achieving the Developmental task leads to success with

Learning to get along with age mates

The client was able to achieve this task since she was able promote and attain many friends which are basically her classmates and that they are able to play together especially in school. The patient was able to attain this task since she was able to promote good inter action towards her peers at school and at home. She also promotes attitudes that comply within the values taught to her by her parents. The client was able to achieve this task since she was able to play games appropriate for her gender like playing as a mother of a family and games suited for girls such as playing dolls and stuff toys rather than luksong tinik and action figures.

Building wholesome attitudes towards oneself as a growing organism

Learning on appropriate masculine or feminine social role

tasks in later stages in life. In the case of our patient, she is on the middle childhood stage (6-13 years old). According to Robert Havighurst, the individual must have the capability to learn new skills necessary for ordinary games. The tasks are as follows:

Developing concepts necessary for everyday living Developing conscience, morality and skill of values

Our client was able to attain this task since she was able to promote good hygiene and other activities of daily living. Our client was able to attain this task since she was taught by her parents and her teacher at school about certain values in which she had applied to her life such as giving respect to the elders and knowing what is right and what is wrong. The patient was able to attain this task since she can perform certain activities f daily living without the assistance of her parents such as eating and taking a bath. The patient was able to attain this task since she has interest towards social groups and she remained neutral to the issues concerning various institutions on the community.

Achieving personal independence.

Developing attitudes towards social groups and institutions

ANATOMY AND PHYSIOLOGY

Circulatory System The cardiovascular/circulatory system transports food, hormones, metabolic wastes, and gases (oxygen, carbon dioxide) to and from cells. Components of the circulatory system include:

blood: consisting of liquid plasma and cells blood vessels (vascular system): the "channels" (arteries, veins, capillaries) which carry blood to/from all tissues. (Arteries carry blood away from the heart. Veins return blood to the heart. Capillaries are thin-walled blood vessels in which gas/ nutrient/ waste exchange occurs.)

heart: a muscular pump to move the blood There are two circulatory "circuits":

Pulmonary circulation, involving the "right heart," delivers blood to and from the lungs. The pulmonary artery carries oxygen-poor blood from the "right heart" to the lungs, where oxygenation and carbon-dioxide removal occur. Pulmonary veins carry oxygen-rich blood from tbe lungs back to the "left heart." Systemic circulation, driven by the "left heart," carries blood to the rest of the body. Food products enter the sytem from the digestive organs into the portal vein. Waste products are removed by the liver and kidneys. All systems ultimately return to the "right heart" via the inferior and superior vena cavae. A specialized component of the circulatory system is the lymphatic system, consisting of a moving fluid (lymph/interstitial fluid); vessels (lymphatics); lymph nodes, and organs (bone marrow, liver, spleen, thymus). Through the flow of blood in and out of arteries, and into the veins, and through the lymph nodes and into the lymph, the body is able to eliminate the products of cellular breakdown and bacterial invasion. Blood Components

Adults have up to ten pints of blood.

Forty-five percent (45%) consists of cells platelets, red blood cells, and white blood cells (neutrophils, basophils, eosinophils, lymphocytes, monocytes). Of the white blood cells, neutrophils and lymphocytes are the most important.

Fifty-five percent (55%) consists of plasma, the liquid component of blood.

Major Blood Components Modified from: Joel DeLisa and Walter C. Stolov, "Significant Body Systems," in: Handbook of Severe Disability, edited by Walter C. Stolov and Michael R. Clowers. US Department of Education, Rehabilitation Services Administration, 1981, p. 37. Component Type Source Bone marrow Platelets, cell fragments life-span: 10 days Bone marrow, Lymphocytes (leukocytes) spleen, lymph nodes Red blood cells (erythrocytes), Filled with hemoglobin, a compound of iron and protein Neutrophil (leukocyte) Bone marrow life-span: 120 days Bone marrow Phagocytosis Oxygen transport Immunity T-cells attack cells containing viruses. B-cells produce antibodies. Blood clotting Function

Plasma, consisting of 90% water and 10% dissolved materials -- nutrients (proteins, salts, glucose), wastes (urea, creatinine), hormones, enzymes

1. Maintenance of pH level near 7.4 2. Transport of large molecules (e.g. cholesterol) 3. Immunity (globulin) 4. Blood clotting (fibrinogen)

Vascular

System

the

Blood

Vessels

Arteries, veins, and capillaries comprise the vascular system. Arteries and veins run parallel throughout the body with a web-like network of capillaries connecting them. Arteries use vessel size, controlled by the sympathetic nervous system, to move blood by pressure; veins use one-way valves controlled by muscle contractions. BLOOD CLOTTING

When blood vessels are cut or damaged, the loss of blood from the system must be stopped before shock and possible death occur. This is accomplished by solidification of the blood, a process called coagulation or clotting. A blood clot consists of

a plug of platelets enmeshed in a network of insoluble fibrin molecules.

Platelet aggregation and fibrin formation both require the proteolytic enzyme thrombin. Clotting also requires:

calcium ions (Ca2+)(which is why blood banks use a chelating agent to bind the calcium in donated blood so the blood will not clot in the bag).

about a dozen other protein clotting factors. Most of these circulate in the blood as inactive precursors. They are activated by proteolytic cleavage becoming, in turn, active proteases for other factors in the system. By tradition, these factors are designated by Roman numerals. I find this somewhat confusing and will use Arabic numerals instead.

INITIATING THE CLOTTING PROCESS

Damaged cells display a surface protein called tissue factor (TF) Tissue factor binds to activated Factor 7. The TF-7 heterodimer is a protease with two substrates:
o o o

Factor 10 and Factor 9 Let's follow Factor 10 first.

Factor 10 binds and activates Factor 5. This heterodimer is called prothrombinase because it is a protease that converts prothrombin (also known as Factor II) to thrombin. Thrombin has several different activities. Two of them are:
o

proteolytic cleavage of fibrinogen (aka "Factor I") to form:

soluble molecules of fibrin and a collection of small fibrinopeptides

activation of Factor 13 which forms covalent bonds between the soluble fibrin molecules converting them into an insoluble meshwork the clot.

(Thrombin and activated Factors 10 ("Xa") and 11 ("XIa") are serine proteases. Link to discussion.) AMPLIFYING THE CLOTTING PROCESS The clotting process also has several positive feedback loops which quickly magnify a tiny initial event into what may well be a lifesaving plug to stop bleeding.

The TF-7 complex (which started the process) also activates Factor 9.

Factor 9 binds to Factor 8, a protein that circulates in the blood stabilized by another protein, von Willebrand Factor (vWF). This complex activates more Factor 10. Factor 5 Factor 8, and Factor 11 (all shown above with green arrows).

As thrombin is generated, it activates more

o o o

Factor 11 amplifies the production of activated Factor 9.

Thus what may have begun as a tiny, localized event rapidly expands into a cascade of activity. PLATELETS Platelets are cell fragments produced from megakaryocytes. Blood normally contains 150,000 to 400,000 per microliter (l). If this value should drop much below 20,000/l, there is a danger of uncontrolled bleeding. This is because of the essential role of platelets

in maintaining the integrity of the adherens junctions that provide a tight seal between the endothelial cells that line the blood vessels; in forming a clot where blood vessels have been broken.

When blood vessels are damaged, fibrils of collagen in the extracellular matrix (ECM) are exposed. Platelets then begin to adhere to the collagen through the action of

specific receptors for collagen present on their plasma membrane von Willebrand factor which links the platelets to the collagen.

These actions cause a plug of platelets to form at the site. THE BOUND PLATELETS RELEASE

ADP and thromboxane A2, which and activate still more platelets circulating in the blood. (This role thromboxane accounts for the beneficial effect of low doses of a cyclooxygenase inhibitor in avoiding heart attacks.)

recruit of aspirin

tissue factor serotonin, which enhances their clumping and promotes constriction of the blood vessel.

ReoPro is a monoclonal antibody directed against platelet receptors. It inhibits platelet aggregation and appears to reduce the risk that "reamed out" coronary arteries (after coronary angioplasty) will plug up again. CONTROLLING CLOTTING While the ability to clot is essential to life, the process must be carefully regulated. Inappropriate clot formation, especially in the brain or lungs, can be life-threatening. ANTITHROMBIN III As its name suggests, this plasma protein (a serpin) inhibits the formation of thrombin. It does so by binding to and thus inactivating:

prothrombin factor 9 factor 10

Heparin is a mixture of polysaccharides that bind to antithrombin III, inducing an allosteric change that greatly enhances its inhibition of thrombin synthesis. Some surgical patients, especially those receiving hip or heart valve replacements, and people at risk of ischemic stroke (clots in the brain), are given heparin.

PROTEIN C With its many clotting promoting activities, it is probably no accident that thrombin sits at the center of the control mechanism.

Excess thrombin binds to cell-surface receptors called thrombomodulin. The resulting complex activates a plasma protein called Protein C and its cofactor Protein S. Together these inhibit further thrombin formation
o o

directly by inactivating Factor 5 and indirectly by inactivating Factor 8.

Some inherited disorders that predispose to spontaneous clots, especially in the leg veins:

inherited deficiency of Protein C or Protein S; inherited mutation in the Factor 5 gene producing a protein that no longer responds to the inhibitory effect of Protein C.

Recombinant Protein C is now available to treat people threatened with inappropriate clotting, e.g., as a result of widespread infection (sepsis). VITAMIN K Vitamin K is a cofactor needed for the synthesis (in the liver) of

factors 2 (prothrombin), 7, 9, and 10 proteins C and S

So a deficiency of Vitamin K predisposes to bleeding. Conversely, blocking the action of vitamin K helps to prevent inappropriate clotting. Warfarin (aka coumadin) is sometimes prescribed as a "blood thinner" because it is an effective vitamin K antagonist. (Warfarin is also used as a rat poison because it can cause lethal (internal) bleeding when eaten.)

ETIOLOGY
Dengue Etiologic Factors Aedes Aegypti Remarks Rationale Dengue fever is a flu-like viral illness that is passed to humans through the bite of a mosquito which is the aedes aegypti Justification The patient experienced mosquito bites which would have a high probability that it carried a serotype of the dengue virus The patient experienced dengue like symptoms which led to her diagnosis of DHF 1

Flavivirus

This type of virus is the causative agent of DHF

Predisposing factors Tropical Countries

Remarks

Rationale Tropical countries are more likely to have higher reported cases for dengue since the environment of these countries favors the growth of mosquitoes.

Justification Patient is a Filipino and living in the Philippines which is included in the tropical countries.

Immune status to Dengue Virus

A patient having infected with one of the 4 serotypes of dengue may develop immunity from it and not from the other 3 serotypes.

The patient did not have any history of dengue which makes her unprotected to any of the 4 subtypes of dengue virus.

Precipitating Factors Dirty surroundings with stagnant water (environment)

Actual

rationale Stagnant waters and dirty surroundings increases the breeding sites of mosquitoes

Justification The patient's environment at home had breeding places for mosquitoes as well as in their school, there are even umerous reports that there were many students infected with the said virus in their school

SYMPTOMATOLOGY
Dengue Symptoms 1. Fever Remarks Rationale Fever is part of our bodys immune response in fighting infection. Leukocytes release pyrogen that increases the temperature in the thermoregulator in the hypothalamus. Monocytes and B-cells also induce fever through the cytokines they release. 2.Leukopenia and thrombocytopenia The virus causes precursor in the bone marrow specifically the white blood cells and platelets. The patient both experienced thrombocytopenia as evidenced in her lab results; PC=37 Justification Prior to admission the patient experienced a very high fever. And until the admission the patient still had fever but was regulated by drugs.

destruction of the blood cell Leukopenia and

3.Increased hematocrit

This happens due to the plasma leakage an immune response causing the blood plasma shift to extravascular spaces causing increase in the ratio between red blood cells and plasma.

In the patient's chart, hematocrit was 0.49

4.Weakness

There is weakness due to increase in body's mechanisms to fight the viral infection. The metabolism during infection is higher and it is focused on fighting the infection

The patient also complained of weakness and shows signs of weakness.

5. Bone pain

The bone pain is highly the blood cell precursor in the bone marrow by the virus especially the white blood cells and platelets.

The patient have not have not verbalized any bone pain.

caused by the destruction of experienced any bone pain or

6. Generalized Lymphadenopathy

Lymph nodes are part of the immune system and one of the its response to infection is to swell. This happens when the circulating pathogen gets trapped in the lymph nodes which triggers the

The patient have not shown any signs of lymphadenopathy during the assessment.

inflammatory process. 7. Hypotension X Hypotension occurs when there is already circulatory failure when the plasma/blood leaks into other spaces due to decreased PC. This usually happens in the late stage of the disease 7. Bleeding X Bleeding occurs due to decreased ability of the body to clot due to decreased PC 8. Nausea and vomiting An intense headache causes nausea and vomiting. Patient has vomited in small amount during the course of the disease. 9.Headache Headache may be caused by a very high fever. Upon history taking, the patient verbalized that she experienced any headache. The patient have not shown any signs of bleeding. The patient have not yet experienced any hypotension during the course of the disease.

10. Delayed capillary refill

The hypovolemic effect of the disease causes ineffective tissue perfusion which causes delayed CRT

The patient's CRT was less than 2 seconds and have not yet experienced any hypotension

11.Hepatomegaly

Virus may induce consumptive coagulopathy,depletion of complement

The patient have not shown any signs of liver enlargement in the assessment so as to her history.

proteins,arteritis, all of which may damage hepatocytes. Direct invasion of the hepatocytes causes hepatic damage which in turn causes inflammation. Such effect is the same with viral hepatitis. 12. Rash / Positive tourniquet test / petechiae Rash or the petechiae appears when there's a generalized micro bleeding in the skin. This happens when there's a decrease in PC and the endothelial layer is unable to hold the blood which causes leakage(hemorrhage) of blood into the dermal or submucosal layer The patient showed signs of petechiae especially when tested with the tourniquet test.

PATHOPHYSIOLOGY

DRUG STUDY
GENERI C NAME APAP BRAN D NAME A C P A R A C E T A M O L E T A M I N O P H E N DOSAGE & ROUTE ACTION INDICATI ON ADVERSE REACTION CONTRAIN DICATIONS Paracetam ol should not be used in hypersensi tivity to the preparatio n and in severe liver diseases. Contraindi cation with allergy to acetamino phen Use causiously with impaired hepatic function, chronic alcoholis m and NURSING TEACHING INTERVE POINT NTIONS Do not exceed the recom mende d dosage . Consul t physici an if needed in childre n Avoid using multipl e prepara tions contain ing acetam iniphen . Do not take for longer than 10 days. Take the drug only for complaint s indicated;i t is not an antiinflammat ory agent. Avoid the use of other over-thecounter preparatio ns.they contain acetamino phen and serious overdosag

Adults: Antipy Analgesi PO or PR retic: c By Reduc antipyret supposito es ic in pt. ry,325fever with 60mg q4by aspirin 6 hr or acting allergy, PO, 1000 directl hemosta mg tid to y on tic qid. Do the disturba not hypoth nces, exceed alamic bleeding 4g/day. heatdiathese regulat s, upper PEDIAT ing GI dse, RIC center gouty PATIEN to arthritis TS: PO or cause Commo PR vasodil n cold, Doses ation flu, may be and other repeated sweati viral and 4-5 ng, bacterial times/day which infection ; do not helps s with exceed dissipa pain and five doses te heat. fever. in 24 hr;

Paracetamol only rarely causes gastrointestinal problems or allergic skin reactions. Blood dyscrasia (e.g. thrombocytopenia) methaemoglobinemia, hemolytic anemia A minority of the subjects with so-called aspirin intolerance responds to paracetamol with bronchospasms. It is not safely established if paracetamol can cause a nephropathy, like drug combinations containing phenacetin. predominantly skin allergy (itching and rash), Long-term treatment with high doses may cause a toxic hepatitis with following initial symptoms: nausea, vomiting, sweating, and discomfort. Occasionally a

CLASS IFICAT IO N nonnarcotic analges icantipyr etic

give PO or by supposito ry.

Analge sic: Site and mecha nism of action unclea r.

gastrointestinal discomfort may be seen. HEMATOLOGIC: Methemoglobinemia cyanosis; hemolytic anemia hematuria,anuria;neutro penia,leukopenia, Pancytopenia,thromboc ytopenia,hypoglycemia HYPERSENSITIVITY : rash, fever

pregnancy ,lactation

Give drug with food if GI upset occurs Discon tinue drug if hypers ensitivi ty reactio n occurs

e can occur. If you need an over thecounterpreparatio n,counsult your health care provider. Report rash,unusu al bleeding or bruising,y ellowing skin or eyes,chan ges in voiding patterns.

GENERIC NAME T R A N E X A M I C

BRAN D NAME C Y K L O K A P R O N

SIDE EFFECTS Nausea, vomiting, diarrhea m ight occur. If these persist or worsen, notify your doctor promptly. Very unlikely but report promptly: vision changes, dizziness.

USES:

INDICATI ON -treatment of excessive bleeding resulting from systemic or local hyperfibrin olysis

ADVERSE REACTION

CONTRAINDICATIONS

NURSING INTERVEN TION

CLASSIFIC ATION

This medicatio n is used for shortterm control of bleeding in hemophili acs, including dental extraction procedure s.

Blurred vision or other changes in vision

A C I D

hypotension (dizz iness or lightheadedness; unusual tiredness or weakness) may be associated with too-rapid prophylaxis intravenous in patients administration with coagulopat thrombosis or hy thromboembolism undergoing (pains in chest, surgical groin, or legs Procedure [especially calves]; severe, sudden headache; sudden and unexplained shortness of breath, slurred

-In patients with acquired defective color vision, since this prohibits measuring one endpoint that should be followed as a measure of toxicity. -In patients with subarachnoid hemorrhage. -Anecdotal experience indicates that cerebral edema and cerebral infarction may be caused by CYKLOKAPRON in such patients. -In patients with active intravascular clotting. Defective color vision, acquired (condition precludes assessment of color vision, which may be required to determine toxicity) Hematuria of upper urinary tract origin (risk

Observe Fibrinolytic ten rights Inhibitor of drug administr ation Provide kidney basin at bedside in cases of nausea and vamiiting occurs Raise siderails and unsure client safety. Assess visual changesw hil on medicatio n Report

O R A L

speech, vision changes, and/or weakness or numbness in arm or leg; sudden loss of coordination) depending on site of thrombus formation or embolization

(tran-exAM-ick acid)

of intrarenal obstruction secondary to clot retention in the renal pelvis and ureters if hematuria is massive; also, if hematuria is associated with a disease of the renal parenchyma, intravascular precipitation of fibrin may occur and exacerbate the disease) Hemorrhage, subarachnoid (increased Incidence more risk of cerebral edema and frequent cerebral infarction) Diarrhea Renal function nausea impairment (medication vomiting may accumulate; dosage Incidence adjustment based on the unknown degree of impairment is Unusual recommended) menstrual Sensitivity to tranexamic discomfort acid, history of caused by clotting Thrombosis, of menstrual fluid predisposition to or history of (medication inhibits clot dissolution and may interfere with mechanisms for

unusualiti es or any of the adverse reaction occurs Encourag e patient to verbalize when there are feelings of pain and discomfo rt Monitor vital signs while on medicatio n

maintaining blood vessel patency; it is recommended that tranexamic acid be administered in conjunction with anticoagulant therapy, if at all)

NURSING CARE PLAN

Name of Patient: CAMINADE, MAXINE Age/sex: 7 YR.OLD-FEMALE Nursing care plan no. 1 Date Cues Subjective: 07/21/1 0 7-3 shift Bug naw akong paminaw. Need Nsg. Dx. Objectives At the end of 2 hours span of care, patients temperature will decrease within normal range. (36.5-37.5)

Date of Admission: JULY 19,2010 Room #: ROOM 329-1 Attending Physician: Dr. Naval Interventions - establish rapport to the patient To gain trust and cooperation -monitor vital signs To have baseline data -remove extra/ thick clothing to decrease temperature by means of convection -perform tepid sponge bath to decrease temperature by means of conduction -note chronological and developmental age of client. Children are more susceptible to heatstroke,elderly or impaired individualsmay not be able to recognize and/or act on symptoms of hyperthermia -monitor respirations. Hyperventilation may initially be present,hypermetabolic state(shock or GOAL MET After my 8 hours span of care , the patients temperatur e decreases its temperatur e to normal temperatur e Evaluation

Nutritio -hyperthermia related to naldisease process metabol secondary to DHF I ic pattern

Objective: -her skin is dry and warm to touch Fever is part of our bodys immune response in fighting infection. Leukocytes release pyrogen that increases the temperature in the thermo-regulator in the hypothalamus. Monocytes and B-cells also induce fever through the cytokines they release.

- increased body temperature above normal range; temp: 37.9 cesius

-flushed face

-increased respiratory rate

http://wonder.cdc.gov/wo nder/prevguid/p0000373/ p0000373.asp

acidosis) -monitor/record all sources of fluid loss such as urine(oliguria,and/or renal failure may occur dur to hypothention,dehydration, shock, and tissue necrosis) -maintain bedrest to reduce metabolic demands/oxygen consumption. -discuss importance of adequate fluid intake to prevent dehydration. -review signs and symptoms of hyperthermia.indicates need to prompt intervention

Nursing care plan no. 2 Date/ Time Subjective: 07/22/10 7-3 shift Dili kaayo ko makatulog kay saba kaayo ug init pa jud. Objective: Short duration of sleep with long intervals since date of admission Noisy setting Presenc e of P A T T E R N S L E E P R E S T Cues Need Nursing Diagnosis with Rationale Disturbed sleep pattern Objectives of Care Within my 8 Nursing Interventions Evaluation

1. Establish rapport. R: To gain clients trust and R/T environmental hours span of cooperation. stressors 2o to care, the patient 2. Obtain feedback from patient regarding usual bedtime and hospitalization. will feel rested environmental needs. and be able to R: To determine usual sleep pattern and provide comparative R: Hospitalization can have at least 2-3 baseline. significantly disrupt hours of 3. Arrange care to provide for uninterrupted periods for rest, sleeping patterns. In continuous especially allowing more periods of hospitalized patients, the sleep. sleep at night when possible. R: To establish optimal sleep. most common causes of 4. Explain necessity of disturbances acute insomnia include the for monitoring vital signs. R: To monitor the patients effects of illness, health status. environmental sleep 5. Provide quiet environment and comfort measures. disruption, medication, R: To promote rest and sleep. anxiety, and depression. 6. Provide warm milk. R: To enhance patients ability to fall asleep. http://www.hqlo.com/cont 7. Recommend limiting intake of caffeine. ent/2/1/17 R: To promote sleep. 8. Promote the use of aids to block out light or noise such as sleep mask or

GOAL MET Patient was able to feel rested and had at least 3 hours of continuous sleep.

eyebags Freque nt yawning Weakn ess or tiredness

earplugs. R: To reduce environmental stressors. 9. Provide a cool environment by the use of fans. R: To promote an environment conducive for sleep. 10. Encourage patient to have a warm bath before bedtime. R: To promote rest and sleep.

Nursing care plan no. 3 DATE/ CUES NEED TIME S/O: 07/23/10 7-3 shift Low levels of energy Lying on bed in the whole shift Decreased PC, WBC count Weakness noted Disinterest in surroundin gs and A C T I V I T Y

NURSING DIAGNOSIS Fatigue related to increased metabolic demands secondary to Dengue fever

OBJECTIVE OF CARE Within my 8 ours span of care patient will able to maintain optimum level of energy

INTERVENTIONS 1. Assess patients ability to perform activities to know the patient's limitations. 2. Instruct to avoid any exertional activites. this will minimize the metabolic demand on the patient's body 3. Assist for self-care needs such as changing cloths. to decrease the patient's effort and strength in performing activites . 4. Instruct patient to have rest periods between activities. so that the body will be able to compensate the physiologic demand every after activities.

EVALATION

GOAL MET,

In the course of dengue infection, the body exhausts the body's energy to fight of the infection which will cause exhaustion of cells. This

patient was able maintain optimum levels of energy.

participatio n in activities noted Drowsiness Frequent Yawning noted Slow movements noted

E X E R C I S E

event will lead to increased metabolic demands and while uncompensated the patient will be at risk to feel fatigue Medical Surgical Nursing By: Smeltzer and Bare

P A T T E R N

5 Instruct patient to take adequate rest. Sleeping helps in regaining body energy 6. Promote an environment conducive for resting and sleeping. a non-stimulating environment will help promote rest on the patient 7. Emphasize the importance of proper nutritional intake this will boost the pt's immune system at the same time help compensate and provide energy to the body. 8. Emphasize the importance and benefits of increased OFI and submitting to fluid replacement. proper information dissemination will help the patient understand the importance of complying with the treatment regimen .

Nursing care plan no. 4 Date and Time: 07/24/1 0 7-3 shift Cues: - Decreased platelet count -Eating utensils made of glass are placed near the head of the bed - Body weakness noted -Long untrimmed nails noted Need: H E A L T H P E R C E P T I O N | H E A L T H M A N Nsg. Diagnosis: Risk for Injury R/T possible bleeding episode and low platelet count 2 DHF I, ITP without exudates Objective: Within my 7 hours span of care the patient will be free from injury or bleeding. Nsg. Intervention: 1. Establish rapport with the patient and family. This is to have a good and trustful relationship with the patient and her family and gain their cooperation throughout the exposure. 2. To monitor the client closely. For immediate action in case of bleeding. 3. Instruct the family to keep a close eye on the patient. To reduce chances of accidents and bleeding episodes. 4. Instruct the family and client to report any bleeding episodes such as nose bleeding or gum bleeding. To be able to give instructions or intervene immediately before bleeding worsens. 5. Provide sheets or cover the bed with foam or cloth. To decrease risk of injury that the metal bed provides. 6. Instruct the client and family to be careful when handling the dishes. Broken pieces of glass can cause bleeding due to sharpness. 7. Instruct the patient to wear slippers Evaluation:

GOAL MET Within my 7 hour span of care, the patient was free from injury and bleeding.

With dengue there is decrease in platelets in the body, because of this, the clotting response of the body is diminished and patient may suffer from bleeding episode the shock. http://wonder.cdc. gov/wonder/prevg uid/p0000373/p00 00373.asp

A G E M E N T P A T T E R N

when feet are touching the floor. To avoid injury caused by stepping on something sharp on the floor. 8. Instruct watcher not to give medications not prescribed by the doctor or inform the nurses on duty if there are medications being given without their knowledge. Medications such as aspirin may be given and will only worsen the condition of the client. 9. Instruct the client to avoid scratching. Scratching may cause a break in the skin resulting to injury and bleeding. 10. Instruct the client to have short trimmed nails. Long nails may cause injury to ones skin. 11. Instruct client and family to avoid putting sharp objects near the bed. To keep the client safe.

Nursing care plan no. 5 Date/ Time Cues Subjective: Ate, Wala koy ligo-ligo sukad ning abot ko dire. kapoyan man gud ko , as verbalized by the patient. Objective: -poor hygiene -nails not welltrimmed Need s A C T I V I T Y E X E R C I S E P A T T E R N Nursing Diagnosis Self Care Deficit related to weakness secondary to disease process Objective of care Within 6 hours span of care, the patient will perform measure of proper hygiene Such as a.) trimming of nails b.) Performs with or without assistance in sponge bath c.) oral care Nursing Interventions 1. Establish rapport to the patient to promote cooperation in every interaction and procedures to be done 2. Trim/Cut the nails to prevent acquiring more microorganisms 3. Provide mouth care using bactidol as ordered. If not available use clean water and let the patient gargle, preferably with salt. to provide proper oral hygiene/ proper mouth hygiene for the patient and to minimize halitosis until it will diminish. 4. Encourage the patient to clean the body using wet towel with soap and rinse with water. to provide proper hygiene and to be free from body odor 5. Provide sponge bath for cleansing the hair and be free from dandruff. 6. Apply deodorant on underarms it is an antiperspirant that reduces Evaluation July 24, 2010 After 8 hours span of care, patient performs measures for proper hygiene such as: a.) trimming of nails b.) Performs with or without assistance in sponge bath c.) oral care

07/24/ 10 7-3 shift

Because of body weakness it affects the body to do ADLs resulted to poor hygiene. Bibliography: Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales;Ed10 (2006) by Doenges, Moorhouse and Murr

-weakness noted on both arms and legs

body odor. 7. Change clothing every day after cleansing the body to provide proper hygiene 8. Teach and encourage the watcher or the significant others to provide proper hygiene to provide continuous care to the patient since the patient is unable to do it for himself

PROGNOSIS
CRITERIA Onset of illness Duration of illness GOOD FAIR POOR JUSTIFICATION As soon as the symptoms of dengue manifested, the parents immediately sought medical attention. The patient was able to recover from her illness in a small span of time since she was able to comply with the treatment regimen. Patient's environment in the ward was still conducive for healing. Also the patient's environment in their house was favorable for breeding of mosquitoes which may lead to another dengue infection episode if not intervened Family support Patients family is very supportive. They provide the needs of the patient in terms of the treatment regimen, food, their presence, and taking care of the patient. Willingness to take medications Precipitating Factors Predisposing Factors The patient is willing to take the medication such as taking antipyretics on time and submitting to fluid replenishment. Patient's environment was a major contributive factor for acquiring the dengue infection. Dengue is prevalent in tropical counties and patient was not able to acquire any immunity of the disease since she have not yet experienced any dengue in the past making her vulnerable to the 4 serotypes of dengue.

Environment

CALCULATION Good: 3 x 4= 12 Fair: 2 x 2 = 4 Poor: 1 x 3 = 3 Total: 19 / 7 = 2.71

Legend POOR = 1 FAIR= 2 GOOD = 3 RANGE = 1.0 1.6 RANGE = 1.7 2.3 RANGE = 2.4 3.0

General Prognosis

GOOD

Patient X has a good prognosis since she was able to recover from her illness and was discharged with no episodes of bleeding nor complications during her admission. However, there are still 3 serotypes of dengue virus strain which she has not acquired immunity yet, therefore improvement of her environment is recommended.

DISCHARGE PLAN
Medications Teach the client of the importance of strict compliance of the treatment regimen to hasten recovery. Instruct the client the proper dosage and the right time to take the medicines. Teach the client of the side effects and reactions of the medications given. If adverse reaction is experienced, the physician must be informed. Exercise Advise client not to do strenuous activities and to have adequate rest periods so that the body can focus on healing. Encourage client to exercise within his capability to allow good blood circulation as tolerated by her body.

Treatment Instruct client to have adequate rest and sleep to hasten healing process. Patients family must provide calm, quiet and safe environment to the patient. Instruct the patient/watcher to comply with diagnostic exams so that diagnosis will be faster and more accurate.

Health Teachings Remind parents to empty stagnant water from old tires, trash cans, and flower pots. Remind parents to use mosquito nets or killers that are not harmful to their child. Let the patient be aware of the significant role of personal hygiene such as regular bath in promoting wellness. The importance of hand washing is also explained to the patient to avoid transmission of microorganisms.

Give health teaching regarding the importance of maintaining a safe environment free from injurious materials.

Outpatient Inform the patient to return for follow up check up as scheduled. Encourage patient to cooperate well in his home treatment.

Diet Encourage to eat foods rich in vitamin C and iron. Instruct to have proper diet to promote healing and boost immune system. Encourage to drink fluids frequently and fruit juices.

RECOMMENDATION
To the client: Encourage the client to have good compliance with the medications prescribed to her. Advise the patient to apply mosquito repellent lotion before leaving the house. Inform the patient to wear protective clothing such as long pants, socks, and shoes especially when going to grassy areas. Tell the patient to avoid playing in areas where there are stagnant waters such as puddles, ponds, plant pots, tires, and discarded cans.

To the significant others: The significant others need to provide love and care to the patient so that she can have a faster recovery. Encourage the significant others to make sure that the patient has adequate intake of nutritious food. Inform the family to keep their water containers covered so as to prevent any breeding grounds for mosquitoes. Advise the significant others to keep unscreened windows and doors closed. Promote the use of mosquito nets if possible.

To the health care professionals: The health care team should give the client proper treatment and adequate care which could greatly affect her recovery. They should provide the best quality of care they can offer and ensure that the client is always safe.

To the student nurses: The student nurses should always be prepared in every clinical exposure. They should have proper knowledge and apply the skills that were taught to them by their clinical instructors.

They must follow proper management in performing nursing procedures to avoid errors that may cause detrimental effects on the patient. They should show respect to the patients and care for them in the same way as they would treat their own family members.

To Davao Medical School Foundation: The hospital should provide top quality service to their patients. They should show fair treatment in dealing with the patients and give them the care and compassion that they need. Frequent communication with their patients could help address personal concerns which can improve the clients condition. They should also make sure that the client is provided with a clean and well-ventilated environment which is conducive to their health.

To the Davao Medical School Foundation: The college of nursing should provide students with more clinical exposure that can enhance their skills and apply what they have learned in class. They should properly orient the students before assigning them to different clinical areas so that they would know what to expect.

BIBLIOGRAPHY
BOOKS: Handbook of diseases (thirds edtion) by Sarah Y. Yuan, MD, PhD Nurses Pocket Guide, diagnoses, prioritized interventions and rationales, by Marilynn E. Doengers, Marry Frances Moorhouse 2008 Lippincotts Nursing Drugs Guide by Amy Karch Fundamental of Nursing, standards and practice, third edition by Sue C. Delaune and Patricia K. Lander Anatomy and physiology, fifth edition by Gary A. Thibodeau and Kevin T, Patton Fundamentals of Nursing, concepts, process and practice by Barbara Kozier, Glenora ERB, Audrey Berman and Shirlee Snyder Pathophysiology made incredibly easy 4th edition. Pathophysiology Concepts of Altered Health States by Carol Mattson Porth Medical0surgical Nursing, clinical management for positive Outcomes by Joyce M. black and Jane Hokanson Hawks

INTERNET SOURCES: http://www.healthsystem.virginia.edu/uvahealth/peds_digest/hirschpr.cfm http://www.healthscout.com/ency/68/480/main.html#cont www.Google.com www.Drugs.com http://www.rwjobgyn.org/Atoz/Encyclopedia/article/001140.asp http://www.harborhospital.org/11983.cfm http://www.utmedicalcenter.org/encyclopedia/1/001140.htm