COLEGIO DE SAN JUAN DE LETRAN – CALAMBA School of Nursing Calamba City, Laguna DENGUE HEMORRHAGIC FEVER: A CASE STUDY Submitted by: BIÑAS, MAYET O. BONIFACIO, CYRIL S. BUGUIS, JOHARA A. BURGOS, MYRILL L. CAASI, HECTOR ANTHONY A. CABALFIN, APRIL RHOSE E. CALDERON, APRIL EVISON A. CALUPIG, LOURINE A. CAMO, RACHEL ANNE D. CANICON, HAZELLE G. CAPIO, RENE C. CAPURIHAN, CRIZZA JOY T. CARIÑO, JENNIFER CARMONA, MARICEL M. 4BSN1/GROUP III Introduction Background of the Study Dengue hemorrhagic fever is an acute febrile diseases found in tropics.It is a complication of Dengue fever with
Transcript
COLEGIO DE SAN JUAN DE LETRAN – CALAMBASchool of Nursing
Calamba City, Laguna
DENGUE HEMORRHAGIC FEVER: A CASE STUDY
Submitted by:BIÑAS, MAYET O.
BONIFACIO, CYRIL S.BUGUIS, JOHARA A.BURGOS, MYRILL L.
CAASI, HECTOR ANTHONY A.CABALFIN, APRIL RHOSE E.
CALDERON, APRIL EVISON A.CALUPIG, LOURINE A.
CAMO, RACHEL ANNE D.CANICON, HAZELLE G.
CAPIO, RENE C.CAPURIHAN, CRIZZA JOY T.
CARIÑO, JENNIFER CARMONA, MARICEL M.
4BSN1/GROUP III
Introduction
Background of the Study
Dengue hemorrhagic fever is an acute febrile diseases found in tropics.It is a
complication of Dengue fever with hemorrhages. It is characterized by abnormal
vascular permeability, hypovolemia and abnormal blood clotting mechanism.
The Dengue virus type 1,2,3,4, along with other arboviruse which are chikungunya,
O’ nyong-nyong, west nile and flavi virus are classified as the causative agents. The
vector responsible for the transmission of the virus is the domestic, day- biting
mosquito known as the Aedes aegypti.The vector responsible for the transmission of
the virus is the domestic, day-biting mosquito known as the Aedes aegypti.
Rationale for choosing the case
The researchers decided to choose this case because they wanted to acquire more
knowledge about Dengue Hemorrhagic Fever II. They wanted to use the knowledge
they have acquired in promoting awareness to the people especially the
underprivileged that they should seek for medical care in order to prevent the
development and progression of Dengue Hemorrhagic Fever. The researchers also
wanted to focus on preventive measures.
Significance of the Study
This study will help the nursing profession by providing information about the
proper management and care for patients who have Dengue Hemorrhagic Fever. It
will also educate the people, especially those who have Dengue Hemorrhagic Fever
and vulnerable individuals to seek medical care in order to prevent dengue
Hemorrhagic Fever. It will increase awareness about the importance of having a
healthy lifestyle.
This study will elaborate the interrelatedness of lifestyle habits and developing
Dengue Hemorrhagic Fever.
Scope and Limitation of the Study
This study is focused on the nursing aspect of care to those patients who had,
currently have and are at risk for Dengue Hemorrhagic Fever. This study will only
be used in the nursing profession. The researcher will only be focused their attention
on the medications, diagnostics, care plan, pathophysiology and discharge planning.
This study is not limited to patients who have Dengue Hemorrhagic Fever only, but
it is also for all the people who are interested in the disease. We are more focused on
the primary prevention through health education because primary prevention is the
true prevention.
Patient’s PROFILE
Biographic Data:
Name: Patient XL Case No: 05-992216
Age/Sex: 9/Female Civil status: Child
Birthdate: December 22, 2000 Religion: Roman Catholic
Birthplace: Makati Medical Center
Occupation: grade three student
Present address: Parian, Calamba City, Laguna
Date of Admission: July 18, 2009
Attending Physician: Dr. Moran, LBDHAdmitting Diagnosis: DHF IIChief complaint: abdominal pain; episodes of vomiting
HISTORY OF PRESENT ILLNESS
The patient is a 9 year-old female, a grade three student who was diagnosed with Dengue Hemorrhagic Fever II.
Five days prior to admission the client suffers from having a high fever with a temperature of 39. 4 degrees celcius, Paracetamol was given for relief. After three days the fever subsides and abdominal pain and vomiting of brownish colored vomitus takes place. Due to persistence of the said signs and symptoms, the patient seek consultation and hence admitted at Los Baños Doctors’ Hospital Medical Center with Dr. Moran as her attending physician.
Upon admission the child has experienced gum bleeding with presence of petechiae over the face and lower extremities accompanied by loss of appetite. Hematology examination shows low platelet count with a value of 100 mm3.
During the interview session she has a fever and experiences no gum bleeding at all. Her abdominal pain becomes intermittent.
PAST MEDICAL HISTORY
According to the patient’s mother, she experienced having urinary tract infection when she was five years old. The patient only experiences having common cough and colds occasionally. She also experiences fever before and it was relieved by over the counter drugs and rest. Their family does not seek consultation for regular health check up. She has not been hospitalized and only seeks consultation to their Baranggay Health Center whenever any health problem arises. She did not receive an immunization vaccine for measles. She also denies having allergies to food and drugs. She says that she is allergic to dust and particles.
FAMILY HISTORY
The patient has a family history of hypertension. Her mother and father are both
hypertensive. Her eldest sister is 23 years old, alive and healthy. Followed by a 21 year old male, 20
year old female, 15 year old female which are alive and healthy also and the last is the patient, the
youngest.
Activities of Daily Living
Gordon’s Functional Health Patterns
Before During Hospitalization
Health Perception and Health Management Pattern
The patient sees her pattern of health as normal as she suffered from no serious illnesses before. She manages her health by following her mother’s instructions such as sleeping early and eating foods on regular basis. She also follows proper personal hygiene for her to become healthy.
She believes that wellness will be attained if doctor’s orders are to be strictly followed.
Nutritional and Metabolic Pattern
The patient usually eats vegetables because they have many of it planted in their backyard. She said that her favorite food is junk foods especially chips and salty foods. She is also fond of eating sweets such as chocolates and candies. She usually drinks up to 6 glasses of water a day including other beverages. She is not taking any vitamin supplements.
The patient is forbidden to eat dark-colored foods, carbonated drinks and junk foods.
Elimination Her elimination pattern has somehow deviated from her usual urine and stool elimination. Before her confinement, she usually
During her confinement, she now urinates 5 times a day and defecates 3 times a day. According to her the variation from her
urinates for 7 times a day and defecates at least 2 times per day.
elimination pattern is due to change in appetite and setting.
Rest and Activity A typical day to her would be waking up at around 6:00 am to attend her school. She goes home at 4:00 in the afternoon. She does her home works before eating dinner. She goes to sleep at 9:00 p.m. During her spare time, she plays hide and seek, patintero and piko with her classmates.
She plays board games with her other siblings during confinement. She usually wakes up at 8 o’clock in the morning, takes nap after lunch and goes to sleep at 10 o’clock in the evening.
Sleep-Rest Pattern The client doesn’t have any difficulty in sleeping pattern. She sleeps at around 8 in the evening and wake up early. She doesn’t have the habit of sleeping at daytime. She usually drinks Milk before she goes to Sleep and she usually sleeps at about 10 hours daily.
She usually wakes up at 8 o’clock in the morning, takes nap after lunch and goes to sleep at 10 o’clock in the evening.
Cognitive-Perceptual Pattern
The patient is able to read and write. She is currently in grade three in elementary education and portrays a sharp memory when asked about past experiences and significant others. She also has good eyesight and has a normal functioning for her senses and perception.
Patient’s mother brings with them her books to refresh her of the missed lessons in school.
Self-Perception and Self Concept Pattern
She views herself as a student. A student who needs to fulfill her dreams through studying hard. She also stated that she is a jolly, smart and caring individual.
She has good body posture
and was able to maintain eye
contact upon interview.
Role-Relationships Pattern She is the youngest among her siblings. She helps the other family members by doing and following little
Relationship with the family members is intact, it is evidenced by their presence during their youngest
tasks whenever they ask her to do so. The patient has a good family relationship. She states that she is happy with them and they care and love her so much.
sibling’s confinement. They play board games, and give their youngest sibling pasalubong like fruits.
Sexuality-Reproductive
Pattern
Patient denies having
secondary characteristics like
pubic hair and axillary hair.
But she confirms that her
breasts are becoming bigger
than usual.
Coping-Stress Pattern As a child she also deals with some of stressful events everyday. When she was in school her teacher helps her with
her study and school works. She manages her problems with the help of the significant others.
Her status now of being sick
is one of the greatest stressor
for the client and she was
able to cope up because of
the help of the significant
others
Values-Belief Pattern The client is a catholic and she usually goes to church every Sunday with her family. She state that being polite to them and
Following elderly them is an
important value for her. She
uses “po” and “opo” when
talking to her elder siblings.
V. Physical Assessment
BP: 100/90 mmhg
PR: 78 bpm
Temperature: 38.6 degrees celcius
RR: 18 bpm
Area Assessed Method Used Normal
Findings
Actual Findings Rationale
SKIN
Color and
pigmentation
Lesions
Texture
Moisture
Temperature
NAILS
Nail bed color
Shape
Lesions
Thickness
Capillary refill
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Palpation
Palpation
Light to deep
brown
No lesions, scars
or inflammation
Smooth
Moist
Warm
Pink
Convex
No inflammation
of
the skin around
the nail
Firm
General flushing,
rashes
No lesions, but presence of scars
Smooth
Dry
Warm
Pale
Convex
No inflammation
of the skin
around the nail
Firm
Normal capillary
refill less than 2
sec.
Indicative of
bleeding
Normal
Normal
Due to imbalance fluid in the body
Normal
Imbalance
between
hemoiglobin and
hematocrit results
Normal
Normal
Normal
Normal
(less than 2secs)
HEAD
Size Inspection Proportion to the
body
Proportion to the
body
Normal
Symmetry
HAIR
Color
Texture
Other findings
SCALP
Distribution of
hair
Lesions
FACE
Skin color
Texture
Facial movement
EYES
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
and the skull is
rounded and
smooth
Symmetrical
Black
Curly hair,
straight
No nits/lice
present
Evenly
distributed
No inflammation,
lumps or masses
Light to deep
brown
Smooth
Symmetric facial
movement
and the skull is
rounded
and smooth
Symmetrical
Black
Straight and
smooth
No nits/lice
present
Evenly
distributed
No inflammation,
lumps or masses
Pinkish
Symmetric facial
Symmetric facial
movement
Normal
Normal
Normal
Normal
Normal
Normal
Due to fever
Normal
Normal
External structure
Eyebrows
Eyelashes
Eyelids
EARS
Color
Symmetry
Shape and size
NOSE
Color
Shape
Discharges
MOUTH
Lips
Moisture
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Evenly
distributed
Evenly
distributed,
Evenly
distributed,
curved outward
Same as facial
color
Symmetrical at
the
level of the eyes
corner
Symmetric to
head
No discharges
and
inflammation
Same with facial
color
Pink conjunctiva
Evenly
distributed
Evenly
distributed
Pinkish
Symmetric at the
level of the eyes
corner
No discharges
and
inflammation
Same with facial
color
Symmetric
No discharges
Pink
Dry
Normal
Normal
Normal
Due to fever
Normal
Normal
Normal
Normal
Normal
Normal
Due to fever and
decrease fluid in
TONGUE
Position
Color
Texture
Mobility
Lesions
NECK
Position
Symmetry
Range of
movements
UPPER AND
LOWER
EXTREMITIES
Size
Symmetry
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Palpation
Inspection
Inspection
Inspection
Symmetric
No discharges
Pink
Moist
Positioned at the
center can move
freely
Dull red
Smooth
Can move freely
No lesions or
inflammation
Head centered
Symmetrical
Smooth
movements
without
discomfort
Central position
Dull red
Smooth
Can move freely
No lesions or
inflammation
Head centered
Symmetrical
Smooth
movements
without
discomfort
Symmetric and at
midline position
Equal size
Symmetrical
Pinkish with
the body
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Due to fever and
disease condition
Normal
Skin color
Lesions
Inspection Symmetric and at
midline position
Equal size
Symmetrical
Light to deep
brown
No lesions,
deformities or
inflammation
rashes on both
extremities
No lesions,
deformities or
inflammation
Due to
disease
THEORETICAL FRAMEWORK
Florence Nightingale's core nursing theory has an environmental focus: It was her belief that the environment is an alterable medium that can be used to improve the conditions of Nature and encourage healing. Ventilation, clean air, clean water, control of noise, provision for light, and Adequate waste management are just a some of the elements She believed could be Monitored and improved when necessary.
Nightingale’s theory addresses the prevention of occurrences of Dengue Hemorrhagic Fever. In facilitating proper environmental sanitation we can achieve a surroundings with no presence of any vector that cause its transmission as they can no longer exist if the environment is not suited for their survival hence decreasing the morbidity rate of Dengue in our country. We should be knowledgeable on how to keep our surroundings free from any breeding sites that could serve as a reservoir for the mosquito. As a nurse we should teach our clients how to do proper water storage and environmental sanitation so as to prevent disease occurrence and recurrence
ANATOMY AND PHYSIOLOGY
Blood- a connective tissue
composed of a liquid
extracellular matrix called
blood plasma that dissolves
and suspends various cells and
cell fragments.
1 - HYPERLINK "http://www.psbc.org/education/hematology/blood/blood.htm" Formed elements:
Red blood cells (or erythrocytes)
White blood cells (or leucocytes)
Platelets (or thrombocytes)
2 - HYPERLINK "http://www.psbc.org/education/hematology/blood/plasma.htm" Plasma = water
+ dissolved solutes
Characteristics of Blood
bright red
dark red/purplish
much more dense than pure water
pH range from 7.35 to 7.45
slightly warmer than body temperature
typical volume in an adult is 5 liters
8% of body weight
Major Functions of Blood
Distribution & Transport
Regulation (maintenance of homeostasis)
Protection
Formed Elements
RBC
biconcave disk shape
a hemoglobin carrier
anucleate
No mitochondria
120 lifespan
erythropoietin is the hormone that stimulates RBC production
WBC or Leukocytes
protection from microbes, parasites, toxins, cancer
1% of blood volume; 4-11,000 per cubic mm blood
amoeboid motion
chemotaxis
leukocytosis
leukopoiesis
Colony stimulating Factors and interleukins-stimulates white blood cell formation
Platelets
formed in the bone marrow from cells called megakaryocytes
very small, 2-4 microns in diameter
approximately 250-500,000 per cubic millimeter
essential for clotting of damaged vasculature
Thrombopoietin stimulates the production
Platelet Plug Formation
PATHOPHYSIOLOGY
Precipitating Factors: Predisposing Factors:Presence of drainage nearby AgeNot using mosquito nets, repellantsLive plants at home
Aedes Aegypti↓
Virus goes into circulation↓
Dengue Virus Type II↓
IgG adheres to the platelet↓
thrombocytopenia↓
increased potential for hemorrhage↓
stimulates intense inflammatory response↓
petechial rash, high fever, headache,vomiting, abdominal pain, (+) torniquet test
LABORATORY RESULT
Date: July 18, 20099:15
Fecalysis Report
Result Normal Findings Analysis
Color
Consistency
Yellow
Semi-formed
Yellow
Semi-formed
Normal
Normal
Blood: NegativeRemarks: No ova/intestinal parasite seen
Obtain CBC; assess for infections, renal or liver disease.
Report any evidence of yellow discoloration of skin and eyes, or diarrhea.
Maintain adequate hydration.
Advise patient to report any confusion or disorientation.
COURSE IN THE WARD
Date Doctor’s Order Nursing Assessment and Function
July 18, 20092:33 pmBP: 90/80
Temp: 38.60C
Admit to ROCSecure consentTPR q shiftDAT except dark colored foodsDiagnostic TestCBC, platelet in AMIVF D5LRS 1L X 6 hrs @ 40 gtts/minRanitidine 1 amp IV q 8hrsParacetamol 1 amp IV q 6hrsMonitor Temp and BP q1hrI&O hs and record
Refer
Platelet counts and hematocrits should be monitored repeatedly to review the progress of patients.
Oral and PRN medication is given to the patient at the right time to promote health and maintain wellness.
Intake and output is monitored to check if the patient’s fluid status is within normal.
July 19, 20098:15BP: 100/80Temp: 38.00C
Continue medsTF: D5LRS 1L X 6hrs @ 40gtts/minBP and Temp q 2hrsHCT am
If the hematocrit levels fall dangerously then a blood transfusion should be considered. If the hematocrit values rise the patient should be given fluids intravenously and the fluids carefully monitored to ensure that the patient does not get excess fluids. A rise of more than 20 % as compared to previous levels may be an indication for IV fluids. The doctor should decide based on best judgment of patient's condition.
Continuation of medications to prevent diseases and maintain wellness.
LABORATORY RESULT
Date: July 18, 20099:15
Urinalysis Report
Result Normal Findings Analysis
Color
Transparency
pH
Sp.gravity
Sugar
Protein
Squamous epithelial cell
RBC
Pus Cells
Amorph.Urates/Phosphates
Yellow
Clear
6.5
1.020
Negative
Negative
Occasional
0-2
0-2
Occasional
Yellow amber
Clear to sl. Turbid
4.5-8
1.005-1.030
Negative
Negative
Few
Few
Few
Few
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
LABORATORY RESULT
Date: July 18, 2009
Hematology Report
Result Normal Findings Analysis
White blood cell
Hemoglobin
Hematocrit
Segmenters
Lymphocytes
Platelet count
12 x 10^g/L
10.2 g/dL
31 %
0.73
0.27
100 x 10^g/dL
5-10 x 10^g/L
F: 13.0-18.0 g/dL
39-54 %
0.60-0.70
0.20-0.30
150-450 x 10^g/L
Increased due to presence of infection
Decreased due to bleeding or hemorrhage
Decreased due to bleeding or hemorrhage
Increased due to high glucose level in the
blood
Normal
Due to presence of bleeding
Date: July 19, 2009, AM
Hematology Report
Result Normal Findings Analysis
White Blood Cells
Hemoglobin
Hematocrit
11.9 x 10^g/L
8.5 g/dL
29 %
5-10 x 10^g/L
F: 13.0-18.0 g/dL
39-54 %
Increased due to presence of infection
Decreased due to bleeding or hemorrhage
Segmenters
Lymphocytes
Platelet Count
0.65
0.35
110 x 10^g/dL
0.60-0.70
0.20-0.30
150-450 x 10^g/L
Decreased due to bleeding or hemorrhage
Normal
Increased due to viral infection
Due to presence of bleeding
Date: July 19, 2009, PM
Hematology Report
Result Normal Findings Analysis
White Blood Cells
Hemoglobin
Hematocrit
Segmenters
Lymphocytes
Platelet Count
10 x 10^g/L
9.5 g/dL
29 %
0.68
0.32
113 x 10^g/dL
5-10 x 10^g/L
F: 13.0-18.0 g/dL
39-54 %
0.60-0.70
0.20-0.30
150-450 x 10^g/L
Normal
Decreased due to bleeding or hemorrhage
Decreased due to bleeding or hemorrhage
Normal
Increased due to viral infection
Due to presence of bleeding
Date: July 20, 2009, AM
Hematology Report
Result Normal Findings Analysis
White Blood Cells
Hemoglobin
Hematocrit
Segmenters
Lymphocytes
Platelet Count
9.8 x 10^g/L
9.7 g/dL
29 %
0.69
0.36
126 x 10^g/dL
5-10 x 10^g/L
F: 13.0-18.0 g/dL
39-54 %
0.60-0.70
0.20-0.30
150-450 x 10^g/L
Normal
Decreased due to bleeding or hemorrhage
Decreased due to bleeding or hemorrhage
Normal
Increased due to viral infection
Due to presence of bleeding
Date: July 20, 2009, PM
Hematology Report
Result Normal Findings Analysis
White Blood Cells
Hemoglobin
Hematocrit
Segmenters
9.8 x 10^g/L
10.3 g/dL
31 %
0.57
5-10 x 10^g/L
F: 13.0-18.0 g/dL
39-54 %
0.60-0.70
Normal
Decreased due to bleeding or hemorrhage
Decreased due to bleeding or hemorrhage
Lymphocytes
Platelet Count
0.43
133 x 10^g/dL
0.20-0.30
150-450 x 10^g/L
Decreased due to low glucose level in the
blood
Increased due to viral infection
Due to presence of bleeding
Date: July 21, 2009, AM
Hematology Report
Result Normal Findings Analysis
White Blood Cells
Hemoglobin
Hematocrit
Segmenters
Lymphocytes
Platelet Count
8 x 10^g/L
10 g/dL
30 %
0.68
0.32
85 x 10^g/dL
5-10 x 10^g/L
F: 13.0-18.0 g/dL
39-54 %
0.60-0.70
0.20-0.30
150-450 x 10^g/L
Normal
Decreased due to bleeding or hemorrhage
Decreased due to bleeding or hemorrhage
Normal
Increased due to viral infection
Due to presence of bleeding
Date: July 21, 2009, PM
Hematology Report
Result Normal Findings Analysis
White Blood Cells
Hemoglobin
Hematocrit
Segmenters
Lymphocytes
Platelet Count
10 x 10^g/L
11.4 g/dL
35 %
0.53
0.47
101 x 10^g/dL
5-10 x 10^g/L
F: 13.0-18.0 g/dL
39-54 %
0.60-0.70
0.20-0.30
150-450 x 10^g/L
Normal
Decreased due to bleeding or hemorrhage
Decreased due to bleeding or hemorrhage
Decreased due to low glucose level in the
blood
Increased due to viral infection
Due to presence of bleeding
DISCHARGE TEACHING
Medication
Remind to take the prescribed medicine, having a written reminder of the correct medication, time to take, and the right frequency of the medicine on the way home to establish assurance of medication compliance.
Don’t give aspirin and NSAID’s, they increase the risk of bleeding. Any medicines that decrease platelet count should be avoided.
Exercise
Instruct to avoid excessive activities that may result to stress.Just advised to perform range of motions and repetitive body movements for promotion of optimum health.
Remind about the need for health promotion activities such as reading, watching T.V, etc.
Treatment
Bed rest is advisable during the re-occurrence of fever phase.
Instruct to drink plenty of water or fluids that are available at home and eat nutritious diet. Advised to look for re-occurrence of danger signs and symptoms and report immediately.
HygieneEncourage to continue the routinely hygienic care of the patient
Out-Patient Follow-Up Care
Instruct the family members to have a check-up or to consult physician once a while to monitor patient’s condition and for detection of recurrences and other complications that may arise on to it.
Diet
Instruct the family members to give the client protein rich foods such as meat, fish, eggs
and nuts, vitamin K rich foods such as green leafy vegetables, vit C rich foods(guava and
tomatoes and other citrus fruits), carbohydrates rich food (breads and rice)
Long Term Objectives:
To promote holistic wellness through rendering quality nursing care and health education.
Short Term Objectives:
For Hyperthermia:
1.Within 2 hours of nursing care, the patient temperature will decrease from 38.6°C to 37-37.5°C
For Abdominal Pain:
2. Within 2-4 hours of nursing care the patient will be able to reduced pain felt from 7/10 to 5/10.
For Moderate Dehydration:
3. Within 8 hours of nursing care client will be able to minimize occurrence of fluid deficit as
evidenced by normal skin turgor
NURSING CARE PLAN
ASSESSMENT
NURSING DIAGNOSI
S
BACKGROUND
KNOWLEDGE
PLANNING
INTERVENTION
RATIONALE
EVALUATION
Subjective: “Taas baba po yung lagnat ko,” as verbalized by the patient. Objective:
Skin warm to touchFlushed skinTemperature: 38.6°C
Dry lips notedWBC= 12,000 as seen in laboratory result
Elevated body
temperature related to
inflammatory response
as evidenced by Temp=
38.6, flushed and
warm to touch skin.
Entry of pathogens in the systemic circulation
Regulation of toxins in
the body
Release of pyrogens
Stimulation of
hypothalamus
Increase or alteration of thermoregul
ation
Increase in body temperature
Within 2 hours of nursing care, the patient temperature will decrease from 38.6°C to 37-37.5°C
Independent:
Rendered tepid sponge
bath
Encouraged to increase fluid intake
Promoted surface cooling, loosen
clothing, and cool
environment
Encouraged to have
adequate bed rest
Dependent:
Administered
Paracetamol as ordered
Administered IVF as ordered
To promote surface cooling
To replace fluid loss
due to body heat
Heat is loss by
evaporation and
conduction
To reduce
metabolic demands
To decrease temperature
To support circulating volume and
tissue perfusion
Within 2 hours of nursing care, the patient
temperature will
decrease from 38.6°C to 37.4°C, skin is cool and flushing
is absent.
ASSESSMENT
NURSING DIAGNOSI
S
BACKGROUND
KNOWLEDGE
PLANNING
INTERVENTION
RATIONALE
EVALUATION
Subjective: “Masakit po yung tyan ko,” as verbalized by the patient.
Objective:
ĉ pain scale of 7/10grimace notedirritableweakness noted
Characteristic: stabbing, shooting pain
Onset: “pasumpong-sumpong po”
Location: no exact location “basta sa buong tyan po masakit”
Duration: 2-3 minutes
Acute pain related to
inflammatory response
as evidenced by
verbalization of patient of “masakit
po yung tyan ko”,
pain scale of 7/10,
grimace and irritability.
Entry of pathogens in the systemic circulation
Regulation of toxins in
the body
Release of anti-
inflammatory mediators
Vascular response
Increased capillary
permeability
Hyperemia Cellular exudation
Swelling
Pain
Within 2-4 hours of
nursing care the patient will be able to reduced pain felt
from 7/10 to 5/10.
Independent:
Monitored vital signs
Instructed deep
breathing exercise
Encouraged to have
diversional activites like
watching t.v.
Placed patient on
comfortable position
Encouraged to have
adequate bed rest
Provided therapeutic
touch
To determine alteration
Helps in relieving
pain
To divert attention of patient from
pain
Helps reduce pain
felt
For relaxation
and to prevent stress
To provide comfort
Helps in relieving
pain
After 2-4 hours of
nursing care the patient was able to
reduced pain felt from
7/10 to 5/10.
Exacerbation:Gets worse when pressure is applied in the stomach
Radiation:Radiates in whole abdomen
Relief:“Kapag iniipit ko po”Associated signs and symptoms:
Body weakness, fever
Dependent:
Administered Ranitidine as ordered.
ASSESSMENT
NURSING DIAGNOSI
S
BACKGROUND
KNOWLEDGE
PLANNING
INTERVENTION
RATIONALE
EVALUATION
Subjective: “Tatlong beses po akong nagsuka simula kanina,” as verbalized by the patient.
Fluid Volume Deficit
related to frequent loss
of fluid in the
gastrointestinal tract as
Insufficient fluid intake,
fluid loss from
vomiting
Imbalanced in fluid
Within 8 hours of nursing care client will be able to minimize occurrence of fluid deficit as
Independent:
Monitored Intake and
Output
Ensure accurate
picture of fluid status
To prevent irritation in
After 8 hours of
nursing car the client was able minimize
occurrence of deficit as evidenced
Objective:3 episodes of vomiting watery and small in amountdecreased skin turgordry, pale lipsweakness noted
evidenced by frequent vomiting.
volume
Decreased volume in
intravascular
compartment
Moderate dehydration
evidenced by normal skin turgor.
Withhold foods and fluids for about 3 hours.
Instructed to sip small
amounts of fluids after three hours
fasting.
Instructed to give
crackers and toasted bread.
Dependent:
Provided supplementa
l fluids as indicated. (e.g., IV fluids)
stomach.
To determine if the stomach can already
tolerate fluids
To relieve hunger due
to the fasting done.
Prevents fluctuation
in fluid levels
by normal skin turgor
and verbalization of patient “hindi na po
ako nagsuka.”
Intake (parenteral): 960mL
Urine Output:900mL
Leukocytes, or white cells, are responsible for the defense of the organism.
Round nucleus, produces antibodies, contributes to allergic reactions,tumor control, regulation of the
immune system
Nucleus with 2-4 lobes connected by thin filaments;
Phagocytizes microorganisms and other substances
Red blood cells are responsible for providing oxygen to tissues and partly for recovering carbon dioxide
produced as waste.
Platelets are important in preventing blood loss, releases chemicals for blood clotting
Nucleus with indistinct lobes; releases histamine, which promotes inflammation
The plasma is a slightly alkaline fluid, with a typical yellowish color
Nucleus often bilobed; releases chemicals that reduce inflammation; attacks certain worm parasites
Eosinophils attack parasites and phagocyte antigen-antibody complexes
Neutrophils are very active in phagocyting bacteria and are present in large amount in the pus of wounds.
Unfortunately, these cells are not able to renew the lysosomes used in digesting microbes and dead after
having phagocyted a few of them
Basophil secrete anti-coagulant and vasodilatory substances as histamines and serotonin. Even if they have a
phagocytory capability, their main function is secreting substances which mediate the hypersensitivity
reaction.
The main function of platelets, or thrombocytes, is to stop the loss of blood from wounds (hematostasis).
Monocytes are the precursors of macrophages. They are larger blood cells, which after attaining maturity in the bone
marrow, enter the blood circulation where they stay for 24-36 hours.
