Dengue Breakbone Fever Case Study

8/3/2019 Dengue Breakbone Fever Case Study

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Table of Content

I. Objectives & Introduction

II. Personal Information Data

III.Developmental Data

IV.Assessment

V. Anatomy and Physiology

VI.Pathophysiology

VII.Nursing Care Plans

VIII.Drug Analysis/Study

IX.Discharge Planning

X. Diet Analysis

XI.Prognosis

XII.Evaluation

XIII.Recommendation

XIV.References

XV.Appendices

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General Objective

This case presentation aims to identify and determine the general health

problems and needs of the patient with an admitting diagnosis of Systemic Viral

Illness R/I Dengue Fever . 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 raise the level of awareness of patient on health problems that he may

encounter.

➢ To facilitate patient in taking necessary actions, to solve and prevent the

identified problems on his own.

➢ To help patient in motivating him to continue the health care provided by

the health workers.

➢ To render nursing care and information to patient through the application

of nursing skills.

Dengue fever is an infectious disease carried by mosquitoes and caused by any of four related dengue viruses. This disease used to be called “break-bone” fever because it sometimes causessevere joint and muscle pain that feels like bones are breaking, hence the name. Health expertshave known about dengue fever for more than 200 years.

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Introduction

This epidemic disease, which occurs in tropical areas, is caused by a virus

that is usually transmitted by a mosquito (aedes aegypti). It is rarely seen in the

United States. After an incubation period of five to seven days, symptoms appear

suddenly with high fever up to 106*F (41*C), flushed face, headache, painful

eyeballs, sorethroat, nervousness, disturbed sleep, and severe pain in the head,

back, and joints (hence the term breakbone). Prostration may be great.

About the third or fourth day the temperature usually drops to normal, only

to recur after about three days. The second wave of illness is usually less severe

and shorter in duration, and is accompanied with a rash on the hands and feet

that spreads to arms, legs, and body. The acute symptoms soon end. Usually the

disease is self-limited, but convalescence is slow.

There is no specific treatment, and deaths from the disease are almost

unknown. Good nursing is important. Bed rest and drinking an abundance of

water are essential. Cool enemas and tepid baths will lower the temperature

should it rise above 104*F (40*C). An ice bag to the head usually feels good.

Personal Information Data

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Name: Charlemagne B. Dime

Age: 14 years old

Sex: Male Child

Nationality: Filipino

Religion: Roman Catholic

Parents: Mr. and Mrs. Gregorio Dime

Address: Purok 3 North Poblacion, Medina, Misamis Oriental

Date admitted: January 01, 2012

Time admitted: 10:15 AM

Chief complaints: Fever x 2 Days

Admission Impressions: Systemic Viral Illness R/I Dengue Fever

Attending Physician: Dr. Harold R. Cagang

Vital signs:

Temperature: 38.8 C

Heart Rate: 90 bpm

Respiration Rate: 24 cpm

Weight: 57 kgs.

Developmental Data

Freud’s Psychosexual Stage : Genital stage: Adolescent

develops sexual maturity and learns to establish satisfactory

relationships with the opposite sex.

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Nursing Implications: The client said he is a typical teenager who loves to

explore opposite sex relationship, fond of going out after school and have fun at

the recreational areas with friends of the same age.

Erikson’s Developmental Task: Erikson believed the new interpersonal

dimension that emerges during adolescence is a sense of identity

versus role confusion.

Nursing Implication: According to the client he is well provided with love

and care by his parents. He is being supported and praised for any

decision making he does or any feelings he discussed about events important to

him which makes him sure of himself as a person.

Piaget’s Cognitive Development: Piaget saw

adolescence as the time when cognition achieves its final

form, that of formal operational thought.

Nursing Implication: The client expresses worry of his

illness because he is aware of the possibility of fatality with

this disease if left untreated and unattended.

Assessment

Family History:

Client was born second to the oldest among three siblings. The family has

no health problems, except the mother is currently being monitored with her

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“Hypertension” which is induced due to her fourth pregnancy. However,

Charlemagne is the first in the family being brought to hospital for such illness.

Disease History:

One day prior to his admission, the client said he was gallivanting at the

neighbor’s place last December 31, 2011 (Saturday), and was caught by the rain.

When he reached home he was having chills and hyperthermia. His parents

decided to bring him to hospital since he was vomitus and having chills and

fever.

Physical Assessment Tool:

Neurologic System

The patient was lethargic during admission as observed by NOD.

Digestive System

The abdomen was not distended, soft and there was no palpable mass

upon palpation. Hyperactive bowel sound heard upon auscultation. The patient

vomited once prior to admission.

Respiratory system

His respiratory pattern is not in regular range for his age as evidenced by

his respiratory rate of 25 cpm. His breath is having tachypnea because it is

faster than 20 breaths per minute.

Cardiovascular system

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His apical pulse is 90 bpm and his radial pulse is 88 bpm. His heart

sounds are normal. There are no murmurs heard in the apical pulse upon

inhalation and exhalation.

Musculoskeletal System

The patient manifested good posture and moved voluntarily; he had

symmetrical musculature on both sides of the body. Weakness was noted and

client is complaining of muscle pains and joint pains.

Genito-Urinary System

Patient voided 60-250 cc per shift as monitored through I&O, and yellow in

color as verbalized by the client.

Integumentary System

Thick and curly distributed hair was noted. His nails were convex shape,

smooth in texture, capillary refill of 2 seconds of an untrimmed finger nails with

sweaty palms. His skin was flushy red, warm to touch and fare complexion.

HEENT

The size of the head was in proportion with the body. The eyes were

symmetrical with ears; with painful red eyes (Conjunctival suffusion). When the

eyes were tested papillary reaction to light, the pupil constricted to 2mm. Ear had

no discharges noted. Patient’s throat was functioning well and in normal

condition.

Activity

The patient can move his extremities but with joint pains and muscle

pains. He can move and walk without assistance and was given comfort room

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privileges. He misses watching TV as his only means of recreation at home. He

is bored in the hospital confinement.

Sleep and rest

He usually sleeps at 8:00 pm and rise at 6:00 am. Sometimes his sleeping

pattern is only disturbed when he is not feeling well. The patient feels different

about himself since his hospitalization because of many restrictions imposed by

the health care team plus the uncomfortable condition of the IV fluids attached to

his arm and the muscle and joint pains that is disturbing his comfort to sleep.

Values and Beliefs

The client’s family goes to Catholic church every Sunday and believes in

every celebration of Christmas Eve, New Year’s Day, Lenten season and Easter

Sunday.

Physical Examination

DATE

1-01-12

Vital sign

7-3 3-11 11-7

Temperature 38.8C 38.7C 38.2C

Pulse rate 90bpm 98bpm 100bpm

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Respiratory rate 24cpm 25cpm 22cpm

A. Skin- warm, flushed red, fair in complexion, with sweaty palmsB. Nails- pallor nail bed, dirty with fine capillary refill (approximately within 2seconds)

C. Head/ face -no mass palpated, flushed faceD. Scalp- thick curly hair evenly distributed with no dandruff or lesions

observedE. Eyes- with red sore conjunctival suffusion, no discharges noted, pupils

are equally round and reactive to light and accommodationF. Ears- symmetrical with cerumen, no discharges notedG. Nose-no flaring of nostrils, no discharges notedH. Mouth-dry mucous membranes and pale lipsI. Neck- no mass palpated, without lesions, no enlargement of lymph nodes

and painJ. Chest and Lungs- without crackles and ronchiK. Abdomen- soft, not distendedL. Extremities- weak extremities, muscle and joint painsM. GIT- loss of appetite N. Renal and Urologic changes-decrease urine output(<30ml/hr)O. Cardiovascular changes- noneP. Hematopoietic changes – none

DATE

1-02-12

Vital sign

7-3 3-11 11-7

Temperature 37.8 C 37.2C 38.1 C

Pulse rate 100bpm 110bpm 92bpm

Respiratory rate 29cpm 30cpm 24cpm

A. Skin- warm, flushed red, fair in complexion, with sweaty palmsB. Nails- pallor nail bed, dirty with fine capillary refill (approximately within 2

seconds)C. Head/ face -no mass palpated, flushed face

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D. Scalp- thick curly hair evenly distributed with no dandruff or lesionsobserved

E. Eyes- with red sore conjunctiva suffusion, no discharges noted, pupils areequally round and reactive to light and accommodation

F. Ears- symmetrical with cerumen, no discharges notedG. Nose-no flaring of nostrils, no discharges notedH. Mouth-dry mucous membranes and pale lipsI. Neck- no mass palpated, without lesions, no enlargement of lymph nodes

and painJ. Chest and Lungs- without crackles and ronchiK. Abdomen- soft, not distendedL. Extremities- weak extremities, muscle and joint painsM. GIT- loss of appetite N. Renal and Urologic changes-decrease urine output(<30ml/hr)O. Cardiovascular changes- noneP. Hematopoietic changes – none

Diagnostic and Laboratory Results

Date: January 01, 2012 Time: 10am

Complete Blood Count

Result Normal Value

White Blood Cell 5,900 4.5 – 11.0 X 10/mm

Hemoglobin 14.4 Fem- 11.7 – 14.5 g/dl

Male-13.7- 16.7 g/dl

Hematocrit 42.0 Fem-34.1-44.3 vol %

Male-39.3-48.0 vol %

Platelet 115,000 175,000-350,000/mm

Segmenters 86 45-70%

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Lymphocytes 11 18-45%

Monocytes 03 3-8%

Diagnostic and Laboratory Results

Date: January 02, 2012 Time: 10am

Complete Blood Count

Result Normal Value

White Blood Cell 3,200 4.5 – 11.0 X 10/mm

Hemoglobin 15.9 Fem- 11.7 – 14.5 g/dl

Male-13.7- 16.7 g/dl

Hematocrit 47.9 Fem-34.1-44.3 vol %

Male-39.3-48.0 vol %

Platelet 106,000 175,000-350,000/mm

Segmenters 84 45-70%

Lymphocytes 14 18-45%

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Interpretation:

Platelets is lower than normal range which would risk for bleeding tendency and

coagulation problems or hemolysis.

Lymphocytes is lower than normal range which might need help in fighting against

infection. Indicates decrease immune system.

Segmenters indicates high glucose level in the blood.



Monocytes 02 3-8%

I. Anatomy and Physiology of the Blood

ANATOMY AND PHYSIOLOGY

The Immune System

A second line of defense is

housed within the body: a finely

tuned immune system that

recognizes and destroys foreign

substances and organisms that

enter the body. The immune

system can distinguish between

the body's own tissues and

outside substances called

antigens. This allows cells of the

immune army to identify and

destroy only those enemy

antigens. The ability to identify an

antigen also permits the immune

system to "remember" antigens

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Interpretation:

Platelets rapidly drops more lower than normal range which would risk for bleeding

tendency and coagulation problems or hemolysis.

Lymphocytes is lower than normal range which might need help in fighting against

infection. . Indicates decrease immune system

Segmenters indicates high glucose level in the blood.

WBC a decrease value indicates inadequate inflammatory defenses to suppress

infection and humoral immunity takes place.



the body has been exposed to in the past; so that the body can mount a better

and faster immune response the next time any of these antigens appear.

The immune system also includes other proteins and chemicals that assist

antibodies and T cells in their work. Among them are chemicals that alert

phagocytes to the site of the infection. The complement system, a group of

proteins that normally float freely in the blood, move toward infections, where

they combine to help destroy microorganisms and foreign particles. They do this

by changing the surface of bacteria or other microorganisms, causing them to

die.

➢ Enzyme (EN-zime) is a protein that helps speed up a chemical reaction In

the body.

➢Antigens (AN-tih-jens) are substances that are recognized as a threat bythe body's immune system, which triggers the formation of specific

antibodies against the substance.

➢ Bone marrow is the soft tissue inside bones where blood cells are made.

➢ Lymphatic (lim-FAH-tik) system is a system that contains lymph nodes

and a network of channels that carry fluid and cells of the immune system

through the body.

➢ Immunity (ih-MYOON-uh-tee) is the condition of being protected against

an infectious disease. Immunity often develops after a germ is introduced

to the body. One type of immunity occurs when the body makes special

protein molecules called antibodies to fight the disease-causing germ. The

next time that germ enters the body, the antibodies quickly attack it,

usually preventing the germ from causing disease.

Primarily, the immune system classifies a substance as:

a. Self-non-foreign – they are normally ignored and tolerance and is

exhibited towards these substances. They are not deemed harmful.

b. Non-self – termed as an “antigen”; a specific response is developed to a

specific antigen. The response is then stored in the immune system’s

memory cells for future reference.

Components of the Immune System:

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1. Lymphoid Structures

• Spleen

– Composed of red and white pulp, acts somewhat like a filter.

– The red pulp is the site where old and injured red blood cells are

destroyed.

– The white pulp contains concentrations of lymphocytes.

• Lymph Nodes

– Are distributed throughout the body

– Are connected by lymph channels and capillaries, which remove

foreign material from the lymph before it enters the bloodstream.

1. Immune Cells – Lymphocytesa. B lymphocytes (or B cells) - produce immunoglobulins.

b. T lymphocytes (or T cells) - help control the immune response and

destroy foreign antigens directly.

c. Plasma Cells - are white blood cells that produce large volumes of

antibodies.

1. Tissues – The remaining lymphoid tissues, such as the tonsils and

adenoids and other.

• Mucoid Lymphatic Tissue – contain immune cells that defend the

body’s mucosal surfaces against microorganisms.

Types of Immune Defense:

a. Innate or Nonspecific Immunity

– Also termed as the person’s natural resistance, and are the most

basic and primary of all defenses in the body. (skin, mucusmembranes, phagocytic activity)

1. Immune Cells – Lymphocytes

a. B lymphocytes (or B cells) - produce immunoglobulins.

b. T lymphocytes (or T cells) - help control the immune response and

destroy foreign antigens directly.

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http://en.wikipedia.org/wiki/White_blood_cells

http://en.wikipedia.org/wiki/Antibodies





c. Plasma Cells - are white blood cells that produce large volumes of

antibodies.

1. Tissues – The remaining lymphoid tissues, such as the tonsils and

adenoids and other.

• Mucoid Lymphatic Tissue – contain immune cells that defend the

body’s mucosal surfaces against microorganisms.

2 Types of Immunity

• Active – acquired through previous exposure of the disease or

through immunization wherein the body “actively” participates in

formation of antibodies for future reference.

• Passive – refers to whole, “ready made” immunity acquired from

another, the body is just “passive” in the process of developing

antibodies, as it is already made and given readily.

4 Types of Active Immunity

a. Humoral Immunity

b. Mucosal Immunity

c. Cell-mediated Immunity

d. Delayed HypersensitivityReaction

Antibodies or Immunoglobulins – developed from B-cells through the stimulation

of cytokines produced by helper T-cells in the presence of an antigen. They

attach to specific determinant sites on antigens, and carries out phagocytosis

and initiating inflammation.

IgG 75% Crosses placental barrier; present in circulation and tissue

spaces; antiviral, antitoxic and anti-bacterial properties;

activates complementIgA 15% Found in body secretions and breast milk; protects mucous

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membranes from microorganismsIgM 10% Forms natural ABO antibodies; present in early immune

responses; activates complementIgE .2% Hypersensitivity reaction mediator; Involved in parasitic

infectiousIgD .004% Necessary for maturation of B lymphocytes

Hematologic System

Two types of blood vessels carry blood throughout our bodies:

1. Arteries carry oxygenated blood (blood that has received oxygen from the

lungs) from the heart to the rest of the body.

2. Blood then travels through veins back to the heart and lungs, where it

receives more oxygen.

The blood that flows through this network of veins and arteries is whole blood,

which contains three types of blood cells:

1. Red blood cells (RBCs)

– (also called erythrocytes) are shaped like slightly

indented, flattened disks. RBCs contain the iron-rich

protein hemoglobin. Blood gets its bright red color when

hemoglobin picks up oxygen in the lungs. As the blood

travels through the body, the hemoglobin releases

oxygen to the tissues.

– The body contains more RBCs than any other type of cell, and each has a

life span of about 4 months. Each day, the body produces new RBCs to

replace those that die or are lost from the body.

1. White blood cells (WBCs)

– (also called leukocytes) are a key part of the body's

system for defending itself against infection. They can

move in and out of the bloodstream to reach affected

tissues. Blood contains far fewer WBCs than red blood

cells, although the body can increase WBC production

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to fight infection. There are several types of WBCs, and their life spans

vary from a few days to months. New cells are constantly being formed in

the bone marrow.

– Certain types of WBCs produce antibodies, special proteins that recognize

foreign materials and help the body destroy or neutralize them. The white

cell count (the number of cells in a given amount of blood) in someone

with an infection often is higher than usual because more WBCs are being

produced or are entering the bloodstream to battle the infection.

1. Platelets

– (also called thrombocytes) are tiny oval-shaped

cells made in the bone marrow. They help in theclotting process. When a blood vessel breaks,

platelets gather in the area and help seal off the

leak. Platelets survive only about 9 days in the

bloodstream and are constantly being replaced

by new cells.

– Platelets and clotting factors work together to form solid lumps to seal

leaks, wounds, cuts, and scratches and to prevent bleeding inside and on

the surfaces of our bodies. The process of clotting is like a puzzle with

interlocking parts. When the last part is in place, the clot happens — but if

even one piece is missing, the final pieces can't come together.

Pathophysiology of Dengue Fever

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Predisposing PrecipitatingGeographical area-Tropical islands Environmental conditionsIn the Philippines (Asia Pacific) Immuno-compromise

Mosquito carrying dengue virus

Soldier, StudentsSweaty skin

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

Bite from mosquito (portal entry in the skin) Redness & itchiness

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

Virus disseminated rapidly into the blood and stimulatesWBCs including B-lymphocytes that produces and

secretes immunoglobulins (antibodies), andmonocytes, macrophages, neutrophils

Diagnostic Hematology:

WBC 12,900/cumm (5,000-10,000)

Lymphocytes 49% (20-40%)

Antibodies attach to the viral antigens, and thenmonocytes/macrophages perform phagocytosis through Fc receptor w/in the cells

and dengue virus replicates in the cells.

Entry to Spleen

Diagnostic hem:

Monocytes:42%

Neutrophils 49%

Entry to Bone

Recognition of dengue antigen on infected monocyte

Release of cytokines w/c consist of vasoactive agents such as interleukins, tumor necrosis factor, urokinase and plateletactivating factors w/c stimulates WBCs and pyrogen release

Signs/Symptoms :

Febrile:38.6*C Diaphoresis,warm skin, flushed,

Headache of 3/10 pain scale Dengue

Narrative Pathophysiology of Dengue Fever

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Dengue fever is a severe potentially deadly infection spread by Aedes

Aegypti mosquitoes through salivary glands that enters human skin portals

(biten). Dengue virus inoculates in blood circulation and incubates within 3-14

days. Virus disseminated rapidly into the blood and stimulates WBCs including B-

lymphocytes that produces and secretes immunoglobulins (antibodies),

monocytes, macrophages, and neutrophils. At this stage, there will be an

increase of WBCs and Lymphocytes. Antibodies attach to the viral antigens, and

then monocytes/macrophages perform phagocytosis through Fc receptor within

the cells and dengue virus replicates in the cells. Replicated virus cells will then

enter the Spleen and Bone Marrow. Within this period the monocytes and

neutrophils will decrease. Dengue viral antigen will be recognized on the infected

monocyte. Release of cytokines will stimulate WBCs and the release of pyrogens

A manifestation of hyperthermia, diaphoresis, warm skin, flushed face, and

headache is usually shown. Virus attacks liver and spleen and causes cell death

and other complications such as intense bleeding, pulmonary edema, shock, liver

cirrhosis or death.

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NURSING CARE PLANNursing Diagnosis:

Hyperthermia related to illness, exposure to viral/bacterial environment.Cause Analysis:

Pyrexia is common if inflammation is extensive. If fever infection has caused inflammation, fever can be severe dependingon particular microorganism. Fever results from the release of pyrogens.

CUES OBJECTIVES NURSINGINTERVENTIONS RATIONALE EVALUATION

Subjective:“Gi takigan ko, ugtaas ako hilanat, nagsakit ako ulo gikangahapon”, asverbalized by thepatient.

Objective:Flushed skinFever: 38.8*CDiaphoresis

Red EyesInc. Resp. RateChillsHeadacheDec. platelet count

LTO:

At the end of 2 daysintervention the patientwill be able:

• to recover fromdecreasingplatelet count.

STO:

At the end of 8 hoursintervention the

patient will be able to:

• Maintain bodytemperaturebelow 37.8*C

Independent:

1. Determineprecipitatingfactors.

2. Assess vital signsespeciallytympanic or rectaltemps.

3. Provide fluids bymouth.

4. Provide coldpacks and tepidsponge bath.

1. Identificationandmanagement of underlyingcause areessential torecovery.

2. To provideaccurate coretemperature.

3. to decrease

warmth andincreasesevaporativecooling.

4. to promotecooling &lowering temp.

After series of intervention thepatient:

• Was not yetrelieved of fever thoroughly.

• Plateletsrapidlydecreasesand patientwas

transferredfor a tertiarycare.Butpatient isrelieved w/fever after immediateinterventionsgiven.

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Collaborative:1. Provide

antipyreticmedications PRN

1.To prevent cellular damage, delirium, andconvulsions.

-Goals are metpartially-


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Acute Pain related to biological factors such as activity of disease process.Cause Analysis:

Fever infection has caused inflammation, fever can be severe depending on particular microorganism. Fever results fromthe release of pyrogens. And causes cell destruction, pain in the body parts and other complications.

CUES OBJECTIVES NURSINGINTERVENTIONS

RATIONALE EVALUATION

Subjective:

“Sakit kayo ulo,akomata, mga bukog ugmuscles”, verbalizedby the client.

Objective:Flushed skinFever: 38.8*CDiaphoresisRed EyesInc. Resp. RateChillsHeadacheDec. platelet countBody malaise

Joint painsMuscle pains

LTO:

At the end of 3 daysintervention the patientwill be able:

• to recover frommuscle and jointpains.

STO:

At the end of 8 hoursintervention thepatient will be able to:

• verbalize

adequate relief of pain or abilityto cope withincompletelyrelieved pain inthe muscle & joints& head.

Independent:

1. Assess pain notinglocation, duration,intensity.

2. Encourageincrease fluidintake.

3. Provide comfortmeasure such asuse of heat/coldpacks,repositioning, quiet

environment .

4. Investigate resultsof platelet count.

Collaborative:1. Administer

antipyretic

1.To provideinformation anddetermineinterventions.

2.To flushbacteria andtoxins andregulate bodytemperature.3.To providerelaxation andrefocusesattention from

pain andenhance copingmechanism.4. indication of Dengue fever infection at risk.

1. Reduces pain,fever, and

After series of

intervention thepatient:

• Was not yetrelieved of on and off 3days fever.Plateletsrapidlydecreasesand patientwastransferredfor a tertiarycare.Howeve

r patient isrelieved w/headachethrough coldpacks.

-Goals are met

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medications PRN/antibacterials/antivirals if prescribed.

infections thatis affectingbody system of the patient.


Imbalanced Nutrition: less than body requirements related to inability to ingest food.Cause Analysis:

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Intake of nutrients insufficient to meet metabolic needs.CUES OBJECTIVES NURSING

INTERVENTIONSRATIONALE EVALUATION

Subjective:“Dili nako kayamagtulon pagkaon,busog perme ako

tiyan,makasuka ko”,as verbalized by theclient.

Objective:AnorexiaFever: 38.8*CVomitusChillsBodymalaise/weaknessFatigue

LTO:

At the end of 3 daysintervention the patient

will be able:

• to demonstrateprogressiveweight gain andstrength.

STO:

At the end of 8 hoursintervention thepatient will be able to:

• verbalize relief from Anorexia.

Independent:

1. Assess Causativefactor for

malnutrition.

2. Determine client’sability to chew,swallow, and tastefood. Evaluateteeth and gumsfor poor oralhealth, note gumbleedings.

3. Preventunpleasantodors/sights.

4. Promote pleasantrelaxing

environmentincluding oral carebefore and after meals.

Collaborative:1. Promote adequate/

timely fluid intake.Limit fluids 1 hour

1.To determinehow to meet

metabolicneeds of patient.

2.All factors canaffect ingestionand or digestionof nutrients.

3.This mayhave a negativeeffect onappetite/eating.

4. To enhance

food intake.

1. To reducepossibility of early satiety.

After series of intervention thepatient:

Was able toimproved hisnutrition intakeby taking fruit juices andslowly taking hotsoups brought tohim.-Goals aremet

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prior to meal.2. Encourage use of

lozenges.

2. To stimulatesalivation whendryness is afactor.

DRUG STUDYDate Ordered: January 01, 2012Name of Drug Classification Why Given to

Patient inRelation to theMechanism of

Contraindication Side Effect NursingConsideration

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ActionGeneric (Brand)Apap,paracetamolAcetaminophen

Dose/Frequency

Prescribed500mg 1tab q 4for PRNT>38.8*C.

RecommendedDose andFrequencyUsual startingdosage based onpatient response.Maximum dose,640 mg/day PO q4* to 6* PRN.

Therapeutic:Nonopioid Analgesicsand Antipyretics

Pharmacologic:Para-aminophenol

derivatives

Stability of the Drug:Stored in a roomtemperature

Unknown.Thought toproduceanalgesia byblocking painimpulses by

inhibitingsynthesis of prostaglandinin the CNS.The drug mayrelieve fever through centralaction in thehypothalamicheat regulatingcenter.

Hypersensitivity todrugs.

IndicationTreatment of mildpain or fever.

Stimulation,drowsiness,nausea,vomiting,abdominal pain,hepatotoxicity,

seizure, renalfailure, hemolyticanemia, CNSstimulation,delirium,vascular collapse,convulsions,coma, death.

Assess patient’stype of pain,location, intensity,duration, temp.,diaphoresis.Assess allergic

reactions:rash,urticariaAssess for chronicpoisoning: rapidpulse, weak pulse,dyspnea,coldclummy skin,reportimmediately.

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Discharge Planning

Medication

Intake of appropriate vitamin supplement and diuretics to increase protection

mechanism of the immune system and decreases renal vascular resistance andmay increase renal blood flow, respectively.

Economic

The use of non pharmaco therapy such as drinking plenty of water will promoteincrease plasma in blood to increase immunity and proper hygiene andpromotion of cleanliness at home and work area.

Treatment

Management of such condition would be through hydration and doing controlmeasures to eliminate vector by promoting cleanliness in the environmentthrough proper disposal of rubber tires, changing of water of lower vases once aweek, destruction of breeding places of mosquito and residual spraying withinsecticides.

Hygiene

Advise to follow proper body hygiene and to maintain cleanliness onsurroundings. This would prevent additional cases of DHF.

Out Patient/ Follow-up

Any odd signs such as fever, petechiae, recurrence of fever, must beimmediately reported to the physician.

Diet

Instruct to eat no dark colored foods or hemoglobin free diet that can interferetest for stools.

Diet Analysis

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Patient having dengue fever must have to follow a normal diet or diet as

tolerated to foster wasting of nutrient which the patient has loss during the

sickness.

The importance of why the patient ordered to have a “No dark colored

food or hemoglobin free diet” is to prevent interference during stool exam results.

It is safe to serve Cheese, milk, eggs, non-leafy vegetables, refined

vegetables, fruits and fruit juices.

Avoid alcoholic and acidic beverages that may irritate the GIT and

stimulate vomiting. Instruct patient to eat foods that are low fat, low fiber, non-

irritating and non-carbonated.

Sample Diet for One Day

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Breakfast: 6:00 – 7:00

• Papaya

• Fried vegetarian tocino

• Boiled camote

• Unpolished rice

• Warm milk

Lunch: 11:45 – 12:15

• Low salt boiled camote tops

• Unpolished rice

• 3 ounces sliced turkey

• 1 lettuce leaf

• 1/2 cup cucumber salad

• 1 medium apple

Evening Meal: 6:30 – 7:00

• 3 ounces broiled fish

• 1/2 cup rice

• 1/2 cup green beans

• 1 cup lettuce salad

•

2 teaspoons margarine

• 1 cup lemon water

Prognosis

30



Typical dengue is fatal in less than 1% of cases. The acute phase of the

illness with fever and myalgias lasts about one to two weeks. Convalescence is

accompanied by a feeling of weakness (asthenia), and full recovery often takes

several weeks.

The prognosis is good as long as the client complies to proper

medications, proper nutrition, adequate hydration and proper hygiene. The

parents can financially support their son for a tertiary care if any complication

arises.

CRITERIA FOR PROGNOSIS BASING FROM THE FOLLOWING

A. Age Good

B. Onset of Illness Poor

C. Duration of Illness Poor

D. Nature of Illness Moderate

E. Support System Good

F. Financial Support Good

G. Compliance of Treatment Good

Evaluation

31

http://www.medicinenet.com/script/main/art.asp?articlekey=64119

http://www.medicinenet.com/script/main/art.asp?articlekey=64119



The patient in this study had undergone supportive and symptomatic

management. He was admitted last January 01, 2012 at MOPH-Gingoog City

and was eventually transferred to Cagayan de Oro City last January 03, 2012 for

a tertiary care due to rapidly dropping platelets caused by Dengue Fever Virus.

Proper nursing care such as water therapy and administration of prescribed

drugs were done to promote comfort and repression of symptoms. Hygiene was

also strictly implemented to avoid risk for further infection. Nursing assistance

was also given to help him in his activities of daily living.

Health teaching is a very important role on the part of the nurses. This is of

great significance to the knowledge deficit of patients regarding health and

illness.

Recommendation

32



Strict compliance to the medical treatment, health teachings and medical

check-up is advised. With proper nutrition and conformity to the medications &

therapy, recovery would be easier and faster.

There is no specific treatment for classic dengue fever, and like most people

you will recover completely within 2 weeks. To help with recovery, health care

experts recommend:

• Getting plenty of bed rest

• Drinking lots of fluids

• Taking medicine to reduce fever

Often health care provider advises people with dengue fever not to take

aspirin. Acetaminophen or other over-the-counter pain-reducing medicines are

safe for most people. For severe dengue symptoms, including shock and coma,

early and aggressive emergency treatment with fluid and electrolyte replacement

can be lifesaving.

The best way to prevent dengue fever is to take special precautions to avoid

contact with mosquitoes. Several dengue vaccines are being developed, but

none is likely to be licensed by the Food and Drug Administration in the next few

years.

When outdoors in an area where dengue fever has been found

Use a mosquito repellant containing DEET, picaridin, or oil of lemon eucalyptus

33



Dress in protective clothing-long-sleeved shirts, long pants, socks, and shoes

Because Aedes mosquitoes usually bite during the day, be sure to use

precautions especially during early morning hours before daybreak and in the

late afternoon before dark.

Other precautions include:

✔ Keeping unscreened windows and doors closed

✔ Keeping window and door screens repaired

✔ Getting rid of areas where mosquitoes breed, such as standing water in

flower pots, containers, birdbaths, discarded tires, etc.

References

➢ Meg Gulanick, Nursing Cared Plans, 6th edition, copyright 2007

➢ Jean Foret Giddens et. al., Mosby PDQ for RN, 2nd edition, copyright 2008

34



➢ Joyce M. Black et. al., Medical Surgical Nursing, 8th edition, copyright

2009

➢ Barbara E. Gould, Pathophysiology for the Health Profession, 3rd edition,

copyright 2006

➢ Judith A. Schilling McCann et. al., Nursing 2007 Drug Handbook,

copyright 2006

➢ Sue E. Huether, Understanding Pathophysiology, 4th Edition, copyright

2008

➢ Barbara C. Long, Medical Surgical Nursing, 3rd Edition, copyright 1993

➢ Saul Kassin, Psychology, 2nd edition, copyright 1998

➢ Camille B. Wortman et. al., Psychology, 3rd Edition, copyright 1988

➢ Amy M. Karch, Focus on Nursing Pharmacology, 4 th Edition, copyright

2008

AppendicesAnnex -A

35



Christ the King CollegeNursing Program

Gingoog CityKardex

Name of Student: Leilani R. Ampo Year Level: 4th year BSNDate of Duty: January 3, 2012

Area of Duty: MOPH- Gingoog (Annex Bldg. Medical Ward)

36

Last name: First name:Middle name: Dime, CharlemagneBalisryAge:14 yearold

Sex:Male

NationalityFilipino

Religion:RomanCatholic

Civil StatusChild

Room/Bed#:207(annex)

Address:Purok 3 North Poblacion, Medina, Misamis Oriental

Contact Number:

Chief Complaints:Fever X 2

days

Date admittedJan. 01, 2012

Time admitted:10:15 AM

Attending Physician:Dr. Harold R.Cagang

Hospital #27-70-58 Medical record ##5

Admission Impressions: Systemic Viral Illness R/I Dengue Fever

Prognosis: Good prognosis as long as client complies with medication, haveproper nutrition, maintains proper hygiene and oral fluid intake. And familycan afford for a tertiary care hospitalization if complication arises.



37



DateOrdered

Diet Remarks Date Ordered LaboratoryExams

Remarks

1-1-12 DAT 1-1-12 CBC č plt,u/a

Result in

No dark coloredFood

1-2-12 Rpt CBC č plt

Result in

3PM1-3-12

Rpt CBC č pltRpt CBC č plt

Result in

Treatment:1-1-12 Vomited

Consent to care signedI&O q shiftRefer accordingly

1-2-12 Continue medsStill for labs

1-3-12 For tertiary referral

Vital Sign’s and I & ODate 1-1-12 1-2-12 1-3-12

Temperature: 38.8ºC 37.8ºC 38.1ºCBlood Pressure: 90/60mmHG 120/70mmHG 120/80mmHg

Heart Rate: 90bpm 88bpm 92bpmRespiration

Rate:

24cpm 25cpm 24cpm

Reference: MOPH-GC card

38

Date Medication Remarks DateOrdered

Time I.V. Fluids Remarks

Time onTime

Consumed

1-1-12 Paracetamol 500 mg 1-1-12 Dƽ 0.3 Nacl@ 20 gtts/min

1 tab q 4º PRN if Dƽ NM іL @SR

T ≥ 37.8º C Dƽ NM іL @SR



Annex-B

Christ the King CollegeGingoog City

Nursing ProgramClient Data Form

Name of Student: Leilani R. Ampo Date:

January 3, 2012

Year Level:4th YR BSN Group:_________ Area: MOPH-Gingoog (Annex

Bldg. medical Ward)

Client’s Information

39



Last name: First name:Middle name: Dime, CharlemagneBalisry

Age:14 yearold

Sex:Male

NationalityFilipino

Religion:RomanCatholic

Civil StatusChild

Room/Bed#:207(annex)

Address:Purok 3 North Poblacion, Medina, Misamis Oriental

Contact Number:

40



Occupation: Date admitted Jan. 01, 2012

Time admitted:10:15 AM

Attending Physician:Dr. Harold R.

Cagang

Reason for Hospitalization (clientquote)Fever X 2 days

Admission Impressions:Systemic Viral Illness R/I Dengue

FeverPrognosis: Good prognosis as long as client complies with medication, haveproper nutrition, maintains proper hygiene and oral fluid intake. And familycan afford for a tertiary care hospitalization if complication arises.

Family History (narrative)Client was born second to the oldest among three siblings. The family has

no health problems, except the mother is currently being monitored with her

“Hypertension” which is induced due to her fourth pregnancy. However,

Charlemagne is the first in the family being brought to hospital for such illness.

41



Personal History: (narrative)

One day prior to his admission, the client said he was gallivanting at the

neighbor’s place last December 31, 2011 (Saturday), and was caught by the rain.

When he reached home he was having chills and hyperthermia. His parents

decided to bring him to hospital since he was vomitus and having chills and with

fever.

42



Admission DataClient is from :

➢ Home: __√_ ➢ Doctor’s Clinic; ___ ➢ School: ___ ➢ Work: ___ ➢ Other Hospital:___ ➢ Others: ___

______________________________ ______________________________ ______________________________

Mode of Admission:➢ Ambulatory; _√__ ➢ Wheelchair: ___ ➢ Stretcher: ___ ➢ Others: ___

_________________________________ _________________________________ _________________________________ _________________________________

Accompanied by: Parents Valuables:➢ None: _√__ ➢ With Client: ___ ➢ Given to relatives: ___

List:____________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________

Laboratory results from outside:Lipunan Hospital Inc., Jan.1, 2012 ,10:00 AM

Person to notify in case of emergency :Name: Gregorio Dime (Father)Address: Medina, Misamis oriental Contact #:

_______________________________

Assessment Tool

Vital Signs➢ Temperature: ___37.8 ° C ____________ Axilla/Oral

➢ Pulse: _______88bpm______________ Radial/Brachial

➢ Apical Pulse: _____90bpm __________

➢ Respiration: ____25cpm___________

➢ Blood Pressure: 120/70mmHg__ Standing/Sitting/Lying Time BP taken:

43



3:50 PM

➢ Height: __5’2” Measured/Estimated

➢ Weight: __57 kgs Measured/EstimatedAllergies/Sensitive to: Any Allergy to Food/Medicine/Latex/others? ___yes _√ _ no

➢ If yes, Please specify: ________________________________

Have used Blood Products? ___yes _√ _ _noReactions? ___yes __√ _ no

Cranial Nerve Assessment1. Cranial nerve I Client has no difficulty identifying scents and aromas.

2. Cranial nerve II Client has no visual problems.

3. Cranial nerve III Client’s pupils in both eyes have equal size and capable of

following moving objects.

4. Cranial nerve IV Client can normally follow moving objects w/ both eyes.

5. Cranial nerve V Facial muscles can move, can chew normally.

6. Cranial nerve VI Eyes can move actively and roll eyes laterally.

7. Cranial nerve VII Can close eyes normally and tongue has good sense of taste.

8. Cranial nerve VIII Has good hearing sensation in both ears.

9. Cranial nerve IX No problem or difficulty of swallowing.

10. Cranial nerve X Strong muscle strength in the head, shoulders,

11. Cranial nerve XI neck, and back….

12. Cranial nerve XII C apable of controlling tongue movement.

SkinSkin Integrity/Condition

√

intact Rash

Lesion

Color

Normal

Pale

Cyanotic

√ Flushed

Moisture

√ Normal

Dry

□

Diaphoretic

44



Ulcer

Bruising

Scars

Burns

Describe: Petechiae seenafter tourniquet test done 1-3-12

____________________________ ____________________________

IV Access

√ Peripheral Left Arm

Central___________________

_

Mottled

Jaundiced

Temperature

√ Warm

Hot

Cool

Cold

Note: 37.8 ° C 1-2-

12

38.9 ° C 1-3-12

Mouth

√ Pink/moist

Ulcers

Lesions

Bleeding

Lips

√ Dry

Cracked

Intact

Lesions

Head

Hair Describe: Client has clean hair and well kept. Noinfestations of lice. Lice Dandruff Lesions Bald

Face Client face is clean, no scars, no acnefound but face is flushed.

Acne Scars Wounds/lesions

Eyes: Vision√ No Impairment

R/L Impaired

R/L Blind

Glass/Contact

Lenses

Color

Describe: Clear

Yellow

√ Red R/L Both

eyes

Drainage R/L

N/A

Ear

Hearing√ No Impairment R/L Impaired R/L hearing Aide Others

________________ ________________ ________________ ________________ ________________

Teeth

Dentures Yes√ No

Caries Yes√ No

Brace Yes

√ No

45



CardiovascularNeck

√ Flat Distended

Apical Pulse√ Regular Irregular Pacemaker Type:

_____________ Rate: 90 bpm

Heart Sound√ Normal AbnormalNote:____________________________

__ ______________________________________ Radial Pulse

√ Strong R/L Faint R/L Doppler R/L (If Applicable)Note:______________________________

Brachial Pulse Strong R/L Faint R/L Doppler R/L (If Applicable)

Pedal Pulse Strong R/L Faint R/L Doppler R/L (If Applicable)

Edema√ No YesSite: ____________________________

Numbness√ No YesSite: Muscle & Joint Pains

46



RespiratoryRetractions

√ N/A Supra Clavicular Intercostal Diaphragmatic

CoughDescribe:

√ N/A Non-productive ProductiveAbility to clear secretions

Yes No

Breath Sounds√ Clear Adventitious: Equal

Tracheostomy Yes√ NoDate inserted:_________________ Date tube change: _____________

Chest tube Yes√ NoLocation;_________________________

_ Oxygen

√ Room Air Nasal cannula Face Mask Trach Mask Endotracheal tube BIPAP CPAP

GastrointestinalAbdominal

√ Soft Firm Rigid Distended

Tenderness√ N/A YesLocation:_____________________

Bowel Sounds√ Present

___________Sounds/min. Absent

Feed Independently√ Yes No

Nasogastric tube/gastrostomy tube Yes√ NoNGT date change:_________________

Constipation Yes√ No

Diarrhea Yes√ NoDate of last BM:___________

Appetite Good Fair√ Poor Nausea Vomiting

Chewing/ Swallowing Difficulties Yes Describe:

_________________ √ No

_________________________

ExtremitiesUpper Lower

Fingers√ Complete

______________________ Arthritis

______________________

Toes√ Complete

______________________ Arthritis

______________________

47



Callus _____________________

Nails Cyanotic Club√ Dirt Cut

Arms Lesions Scars Arthritis Others Muscle pain & Joint

Pain in the arms.

Callus _____________________

Nails Cyanotic Club√ Dirt Cut

Legs Lesions Scars Arthritis Others Muscle pain &

Joint Pain in the leg s.

Genital and AnalMale Female

Lice STI Not Applicable Catheter Hernia Others

Anus Hemorrhoids STI Not Applicable

Lice STI Not Applicable Catheter Hernia Menstruation Date started: Not Applicable

Date ended:

Others ____________________________ _______________________________ ___

Anus Hemorrhoids STI Not Applicable

48



49



Descriptive: Indicate all Observed in the diagram

50

FebrileTemperature38.8ºC

Headache/ Nausea

Red Eyes andOrbital Pain(ConjunctivalSuffusion)

Poor appetite

Flushedface

IncreaseBreathingRate: 25 cpm

Sweaty Palms IVF @ Left ArmD5 NM 1L @20gtts/min

Long Finger

Nails/Dirty

VomitusFeeling

BodyWeakness

Muscle

JointPains

PetechiaeAfter TourniquetTest

Warm Skin



Annex-CCHRIST THE KING COLLEGE

Nursing Program

Gingoog City

Nurses Health Teaching ToolDisease Process (Pathology of the disease) Dengue fever is a potentially deadly infection spread by AedesAegypti Mosquitoes through salivary glands that enters human skinportals ( biten ). Dengue Virus inoculates in blood circulation andinoculates w/in 3 -14 days . Virus attacks Liver and Spleen and causescell death and other complications such as Intense bleeding,Pulmonary Edema, Shock, Liver Cirrhosis and Death eventually.

Medication (12 R’s of medication)No medications available that can provide a cure. Treatment addressesthe symptoms and it also attempts to avoid potential complications.

➢ Non narcotic analgesic and antipyretics to decrease temperatureor regulate pain.

➢ Antibacterial/Antiviral to prevent/treat infections.➢ Antiemetics to treat vomiting.➢ IVF for electrolytes loss (D5LR)➢ Avoid Aspirin because of gastritis and bleeding tendencies.

Diet

➢ Normal diet or Diet as tolerated to foster wasting of nutrientwhich patient unconsciously losses during sickness.➢ NDCF (No dark colored food) or hemoglobin free diet that can

interfere results for stools.➢ Safe to serve: Cheese, milk, eggs, non-leafy vegetables, refined

vegetables, fruits and fruit juices.

Daily Plan of activity✔ Rehydration w/ IVF to correct dehydration✔ Administration of meds order✔ Normal diet

✔ Keep sanitary environment to prevent infections & promotehealing

✔ Bath daily to prevent invasion of microorganisms✔ Clean body & change to clean clothes daily✔ Maintain good oral and body hygiene✔ Exercise✔ Increase fluids intake✔ Regular bowel movement

51



✔ Clean surroundings and spray insecticides✔ Close containers when they collect water✔ Proper garbage disposal

Follow upsHave a follow up consultation & regular check ups

Proper way to take body temperature at homeHave enough rest and avoid heavy strenuous activityAvoid alcoholic beverages while taking medsEmphasize importance of fluid intakeDiscuss use of antipyretics/antibiotics (overdoses cancause liver damage)Compliance to home medicationsWatch for signs and symptoms that require immediatemedical attention

52



Submitted by:

Leilani Rodriguez-Ampo

BSN IV

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Dengue Breakbone Fever Case Study

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