Case Study (DHF)

OBJECTIVES
General
This case study aims to identify and determine the general health problems and needs
of the patient with an admitting diagnosis of Dengue Hemorrhagic Fever, Type 1. This
presentation also intends to help promote health and medical understanding of such condition
through the application of the nursing skills.
Specific
 To raise the level of awareness of significant others on health problems that a toddler
may encounter.
 To facilitate support people in taking necessary actions to solve and prevent the
identified problems on the toddler.
 To help parents in motivating their child to continue the acquisition of the health care
provided by the health workers.
 To render nursing care and information to patient and family through the application of
the nursing skills.
Dengue fever is an infectious disease carried by mosquitoes and caused by any of four
related dengue viruses. This disease used to be called “break-bone” fever because it sometimes
causes severe joint and muscle pain that feels like bones are breaking, hence the name. Health
experts have known about dengue fever for more than 200 years.
I. INTRODUCTION
Dengue fever is found mostly during and shortly after the rainy season in tropical and
subtropical areas of
 Africa
 Southeast Asia and China
 India
 Middle East
 Caribbean and Central and South America
 Australia and the South and Central Pacific
An epidemic in Hawaii in 2001 is a reminder that many states in the United States are
susceptible to dengue epidemics because they harbor the particular types of mosquitoes that
transmit it. Worldwide, more than 100 million cases of dengue infection occur each year. This
includes 100 to 200 cases reported annually to the Centers for Disease Control and Prevention
(CDC), mostly in people who have recently traveled abroad. Many more cases likely go
unreported because some health care providers do not recognize the disease. During the last
part of the 20th century, many tropical regions of the world saw an increase in dengue cases.
Epidemics also occurred more frequently and with more severity. In addition to typical dengue,
dengue hemorrhagic fever and dengue shock syndrome also have increased in many parts of
the world.
Dengue fever can be caused by any one of four types of dengue virus: DEN-1, DEN-2, DEN-3,
and DEN-4. You can be infected by at least two, if not all four types at different times during
your lifetime, but only once by the same type.
You can get dengue virus infections from the bite of an infected Aedes mosquito.
Mosquitoes become infected when they bite infected humans, and later transmit infection to
other people they bite. Two main species of mosquito, Aedes aegypti and Aedes albopictus,
have been responsible for all cases of dengue transmitted in this country. Dengue is not
contagious from person to person.
Symptoms of typical uncomplicated (classic) dengue usually start with fever within 5 to 6
days after you have been bitten by an infected mosquito and include
 High fever, up to 105 degrees Fahrenheit

 Severe headache
 Retro-orbital (behind the eye) pain
 Severe joint and muscle pain
 Nausea and vomiting
 Rash
The rash may appear over most of your body 3 to 4 days after the fever begins. You may get
a second rash later in the disease. Symptoms of dengue hemorrhagic fever include all of the
symptoms of classic dengue plus
 Marked damage to blood and lymph vessels

 Bleeding from the nose, gums, or under the skin, causing purplish bruises
This form of dengue disease can cause death.
Symptoms of dengue shock syndrome-the most severe form of dengue disease-include all
of the symptoms of classic dengue and dengue hemorrhagic fever, plus
 Fluids leaking outside of blood vessels

 Massive bleeding
 Shock (very low blood pressure)
This form of the disease usually occurs in children (sometimes adults) experiencing their
second dengue infection. It is sometimes fatal, especially in children and young adults.
II. BIOGRAPHIC DATA
Name: RGL
Address: 757 U. Soliven St., Brgy. Commonwealth, Quezon City
Age: 3 years old Gender: Female Religious Affiliation: Roman Catholic
Marital Status: Single
Room and Bed No.: 428A
Chief Complaint: Fever
Provisional Diagnosis: Dengue Hemorrhagic Fever I
Attending Physician: Dr. Candelaria
III. NURSING HISTORY
A. PAST HEALTH HISTORY
1. Childhood Illness
The patient had the usual childhood diseases such as measles, mumps, and
chicken pox.
2. Immunization
The patient mother and father stated that she was not fully immunized. The
results show that BCG (+), Hepa B (-), DPT (+), OPV (+), Measles (+), MMR (+), Varicella
(-).
3. Allergies
The patient mother stated that she is positive of Cephalexin however she has no
allergic reactions to any food.
4. Accidents
The patient’s father denied any history of major accident and trauma throughout
her lifespan. Only minor accident took place, like playing outside and accidental falls.
5. Hospitalizations
The patient’s mother and father states that this was her 1st time being admitted
to the hospital.
6. Medications used or currently taken

The patient only takes 5 types of medications. These are Paracetamol 120
mg/5ml, 5ml q 4 hours prn, temperature > 37.8 degrees Celsius. The second medication
is Ibuprofen (Dolan) 200 mg/5ml, 3ml q 6 hours prn, temperature > 38.5 degrees
Celsius. Third is Iterax 5ml Bid. Nutrizinc syrup 5ml OD. Last but not least, Ceftriaxone
450mg Via IV drip q 12hours (ANST). Further explanation about the drug will be
discussed later on the case study.
7. Foreign travel
The parent’s stated that they have not been travelling frequently. They just visit
their relatives in Masbate once in a year.
B. HISTORY OF PRESENT ILLNESS
The patient present condition started 1 week prior to PTC prior to consultation. She
experienced on and off fever undocumented. No signs of cough and colds during that time.
She had a very low resistance because she has a lack of or weak appetite. Since this was not
any major case, she was just given Paracetamol 5 ml.
2 days PTC - Patient started to have rashes after taking Cephalexin.
1 day PTC - Patient still had fever and was known as febrile (39- 40 degrees Celsius).
After having an abdominal pain during this time, the patient’s parents went off to consult.
3 days PTC - Patient still was in a febrile state having hyperthermia with rashes. This
time the patient had vomited of previously ingested food. Lack of appetite was still into
play. She was then consulted to a private physician. She was advised to take several
medications which will help her relieve some pain.
C. FAMILY HISTORY
The patient has no family history of diseases (especially genetic ones). (-) of
hypertension, Diabetes Mellitus, PTB, Malignancy, Heart Disease, Kidney Disease, Liver
disease, Thyroid Disease.
D. Developmental History
The patient had social smile at 3 months, was able to roll over at 5 months and
sit without support at 6 months. At present, the patient can climb stairs with alternating
feet, and can use 3-word sentences e.g. “I love you”.
IV. PATTERNS OF FUNCTIONING
A. PSYCHOLOGICAL HEALTH
1. Coping Pattern
As a child, Ms. RGL can not completely verbalize how well she copes up with her
environment. The patient, when she doesn’t get what she wants, she easily gets agitated. She
bangs the door, throws her things on the floor, and the likes, until her parents try to make
things up for her. After doing so, everything is settled already. She gets what she wanted, or
almost. When on the hospital, she just watches the television to alleviate her sadness and to
divert her thoughts of being hospitalized to other happy feelings.
Analysis:
Coping is dealing with changes in one’s life. It may be a successful or unsuccessful one.
Coping strategies – a way of responding to a change in the environment or situation – varies
from person to person. One thing is for sure, there is never only one way to cope. It can be
effective which results to adaptation, or ineffective which results to mal-adaptation.
Interpretation:
The patient’s coping mechanism is effective for her age because after doing the said acts
and gestures, she gets what she wanted coping to what she is prior to the coping situation.
2. Interaction Pattern
3. Cognitive Pattern
4. Self-Concept Pattern
5. Emotional Pattern
6. Sexuality
The patient has normal reproductive system. Though still young, her pattern of sexuality
is not yet disturbed nor agitated since she is not yet married and remain single as she portrays
the function of a child in the family. The patient has identified the gender she has, her favorite
color, as well as the things she wants to have as to imbibe her sexuality.
Analysis:
Sexuality is a crucial part of a person’s identity. Sex is central to who we are, to our
emotional well-being, and to the quality of our lives. All people have the potential to positively
experience and pleasurably express their sexuality. One does not have to be in relationship to
be sexual. The idea that you need another person to feel sexual is both disempowering and
untrue. Clients do not leave their sexuality behind when they enter the health care system –
their sexuality is always part of them.
Source: Kozier, Barbara, et. al., Fundamentals of Nursing, Concepts, Process and Practice: 7 th ed,
© 2004, Pearson Education, Inc., Page 973.
Interpretation:
The patient has not experienced sexual intercourse since she does not have the
knowledge or information in relation to the function of her body parts and still innocent about
the reproduction process yet her sexuality pattern is still normal because her sexuality is always
a part of herself.
7. Family Coping Pattern
The patient came from a closely bonded and loving family. Her parents are alive and she
has no siblings.
Her parents stated that they experience little misunderstandings at home. When
misunderstandings arise, their daughter cries when she sees them, and they quickly resolve the
problem.
As for their bonding patterns, they eat outside, go out for a stroll at the mall during
Sundays and watch TV at home on weekdays. They give much attention to the patient. They see
to it that the patient feels happy whenever they do such activities.
Analysis:
Family coping mechanisms are the behavior families use to deal with stress or changes
imposed from either within or without. Coping mechanisms can be viewed as an active method
of problem solving developed to meet life's challenges. The coping mechanisms families and
individuals develop reflect their individual resourcefulness. Family may use coping mechanisms
rather consistently over time or may change their coping strategies when new demands are
made on the family.
The family's ability to cope with the stress of illness depends on the member's coping
skills. Families with good communication skills are better able to discuss how they feel about
the illness and how it affects family functioning. They can plan for the future and are flexible in
adapting these plans as the situation changes.
Source: Kozier, Barbara, et. al., Fundamentals of Nursing, Concepts, Process and Practice: 7th
ed, © 2004, Pearson Education, Inc., Page 193-195
Interpretation:
The way in which the patient and her family cope with her present illness as well as
other problems they encountered is normal, because they can deal with the stress these
problems are putting on them and they can find a way to solve and handle them.
B. SOCIO-CULTURAL PATTERNS
1. Cultural Pattern
The patient grew up in the city. Although she went to Masbate already, the province of
her parents, no particular beliefs and/or values had been procured. She acquired values from
her parents and the people around her e.g. friends and relatives like being obedient with what
the parents say. On the other hand, as a toddler, there’s a point wherein she creates her own
values, typically going through a period of extreme negativism. She doesn’t want to do anything
her parents want them to do. Her reply to some of their requests is a very definite “no.”
Analysis:
It is easy for parents to believe their authority is being questioned when this happens
and to worry their child is becoming so disrespectful he or she will have difficulty getting along
in the world. They can be baffled by the extreme change from a happy, cooperative infant who
lived to please them to this irritating, uncooperative child. They may need some help to realize
this is not only a normal phenomenon of toddlerhood but also a positive stage in development.
This change indicates their toddler has learned he or she is a separate individual with separate
needs. It is important that toddlers do this if they are to grown up to be persons who are
independent and able to take care of their own needs and desires.
Source: Pilliteri, Adele. Maternal and Child Health Nursing: Care of the Childbearing and
Childrearing Family, 5th Edition ©2007. Philadelphia, USA, Lippincott Williams & Wilkins, p. 875
Interpretation:
The cultural pattern of the client is focused on the development of a toddler as a

growing child and therefore be considered as accepted within the normative spectrum of a
family with a toddler.
2. Significant Relationships
The significant others considered by the patient are mainly her parents and maternal
aunts and uncles. She looked upon her parents as the greatest people in the world – as far as
they’re concerned. Sometimes, these relationships render reinforcement to the child
specifically positive reinforcement. The aunts and uncles give material things to the client such
as toys making her delightful at times and ceasing her to do what she should not do. Interaction
of the client and her significant others sustains the toddler’s love of silliness, laughter, and joy.
Analysis:
Parents (and significant others) also must grow during the period of toddlerhood. Their
task is to support their child’s growing independence with patience and sensitivity and to learn
methods for handling the child’s frustrations that arise from the quest for autonomy.
Interpretation:
The social life of the patient is mainly sustained by her relationship with her parents and
relatives which in turn contributes to the social development of the toddler.
3.Recreation Pattern
The patient loves to play most of time alone and seldom with other children. Though
she has no idea regarding the significance of engaging with recreation, at least she can
experience its essence. Some of the things she does during playtime are: playing toy cars and
riding a small bike. At home, her pastime is watching TV, particularly, the “Spongebob” show.
Analysis:
The toys toddlers enjoy most are those they can play with by themselves and that
require action. Trucks they can make go, squeaky frogs they can squeeze, waddling ducks they
can pull, rocking horses they can ride, pegs they can pound, blocks they can stack, and a toy
telephone they can talk into are all favourites. These are all toys children can control, giving
them a sense of power in manipulation, an expression of autonomy.
Interpretation:
The toddler’s playing behaviour is within the continuum of wellness behind the reason
that it encompasses the development of a sense of autonomy as described by Erikson.
4. Environment
The patient’s mother and father depicted their residence as well-ventilated, bungalow
type with one room. The house space is conducive according to their perception. The house is
surrounded by waterways that are stagnant which became the ground for the proliferation of
mosquitoes.
Analysis:
Environment is the sum total of all external condition and influences that affects the
development of health of an individual. It has a strong influence on health promotion and
illness-prevention activities of individuals. A safe and healthy environment can be an indicator
of a healthy population because environment is a reflection of the people living in it.
Interpretation:
Considerable factors can be seen in the patient’s environment that contributed to the
transmission of the Dengue virus from the vector to the patient herself.
5. Economic
"Sapat naman ang kinikita naming mag-asawa para sa aming pang-araw-araw.

Nakapagtatabi pa rin kami ng extrang pera just in case na kailanganin sa mga emergency tulad
ng ganito", the mother said. The father is an electrical engineer and the mother is a plain
housewife. Their income is sufficient enough to maintain their day-to-day living.
Analysis:
Financial needs of every person vary considerably. Food, medical cost, and other
expenses are often a financial burden. Adequate financial resources will enable a family to
remain independent.
Interpretation:
The economic status of the patient’s family is stable that even during health crisis; her
family can support their needs.
C. SPIRITUAL PATTERNS
1. Religious Beliefs and Practices
The patient is a Jehovah’s witness, a restorationist, millenarian Christian denomination.

According to the father of the patient, they seldom attend their meetings for worship that are
usually celebrated during Saturdays and Sundays because he is too busy with work. The patient
only knew Jesus Christ as “Bro” in the primetime show in one of the local TV networks.
Analysis:
Children have no concept of right or wrong and beliefs. However, children’s beginning of
faith is established with the development of trust through their relationship with their primary
caregiver. Children imitate the religious gestures and behaviors of others without
comprehending any meaning or significance to the activities.
Interpretation:
At early age, patient tries to assimilate some of the values and beliefs of their parents.
Parental attitudes toward moral codes and religious beliefs convey children what they consider
to be good and bad. The patient’s state of religiosity is still appropriate for her age.
2. Values and Valuing

V. ACTIVITIES OF DAILY LIVING
ACTIVITIES OF DAILY BEFORE DURING ANALYSIS AND

LIVING HOSPITALIZATION HOSPITALIZATION INTERPRETATION
The client as a  The patient is
toddler is not aware subjected to DAT Analysis:
about the (diet as tolerated)
significance of a except for dark- Parents may become
balanced diet as well colored foods. frustrated when
as with the trying to provide
appropriate foods to  The patient is adequate nutrition
be taken at her age. advised to for their toddler
She just leans on her increase fluid because of a
parent’s customary intake as toddler’s varying and
way of acquiring tolerated. She unpredictable
nutrition. Behind the still finds it hard appetite and food
fact that her parents to elevate the preferences.
are lacking sufficient fluid volume of Although a toddler’s
knowledge about her body drinking daily food
proper nutrition to only 250 ml of consumption may
be imposed to her, water a day. vary greatly, energy
NUTRITION she often eats a meal
 The patient is
needs are generally
comprising of less met when sufficient
experiencing a
rice and selected food is supplied in a
loss of appetite.
viand (dishes based positive
She can’t
on her taste environment.
consume a
preference). She’s Children ages 1 to 3
considerable
weak when it comes years should
amount of
to eating major consume 1,300 kcal
nutrients that are
meals (breakfast, daily. Protein and
needed by her
lunch, and supper). carbohydrate needs
body for energy
As claimed by the are often easily met
and strong
parents, the client during the toddler
systemic
usually takes “junk period; diets high in
functions. She
foods” on her diet sugar should be
just usually eats
rather than the foods avoided. Fats should
“lugaw”.
on their table. In generally not be
addition, the mother restricted for
verbalized, “Mahina children under 2
siya kumain ng kanin years old should
at ulam pero madami consume no more
naman uminom ng than 30% of total
gatas (commercially daily calories from
prepared milk).” fat. Adequate
Regarding the water calcium and
intake, the client phosphorus intake is
drinks approximately important for bone
one glass of water mineralization. Milk
according to her should be whole milk
mother on a daily until age 2 years after
basis. The mother which 2% milk can be
reiterated, “Kaunti introduced.
nga uminom ng
tubig, nakakailang Source:
bote naman ng gatas Pilliteri, Adele.
sa araw at gabi(about Maternal and Child
6 bottles in the day Health Nursing: Care
and 2 bottles at of the Childbearing
night).” The parents and Childrearing
are not prompted to Family, 5th Edition
render the necessary ©2007. Philadelphia,
dietary interventions USA, Lippincott
for their child and so Williams & Wilkins,
they just accept the p. 870
way she eats and
drinks.
Interpretation:
The patient’s diet

before
hospitalization and
the diet during her
stay in the medical
center are not
sustaining the
appropriate and
adequate nutrition
required for a toddler
of her age. She lacks
protein for tissue
building in her diet at
present because her
meals consists foods
rich in carbohydrates,
seldom in fruits and
vegetables. The
parents need to
empower their roles
in promoting
adequate intake of a
well-balanced diet of
their child. Feeding
practices to avoid are
giving large amounts
of sweets or chips
and drinking
softdrinks(can induce
imbalance of calcium
and phosphorus) as
they have little
nutritional value.
DEFECATION DEFECATION
The patient takes a  The patient Analysis:
bowel movement defecates at least
once or twice a day. 2 times per day Normal
The color is yellowish resembling the Characteristics of
brown, pungent in stool of a goat Stool
odor, and the (small, rounded
consistency is fecal material). Volume – variable
semisolid (tubular).  Pain is not elicited Color – Child: yellow
Bowel elimination is during the process to brown
not quite hard to of excretion Odor – pungent; may
perform (without any  Fecal color is dark be affected by foods
physiologic and/or brown ingested
psychologic  Consistency is Consistency – soft,
interferences). She’s semisolid semisolid, and formed
under toilet training.  Bowel control is Shape – formed stool
ELIMINATION exhibited is usually about 1 inch
MICTURITION 92.5 cm) in diameter
The patient voids an MICTURITION and has the tubular
average of 4 times a  The patient shape of the colon,
day. Urine color is urinates less often but may be larger or
yellow with aromatic than prior to smaller, depending on
smell. She doesn’t felt hospitalization the condition of the
pain or difficulty in due to her colon
urinating (dysuria). decreased intake Constituents – waste
She’s starting to be of fluids (2x a day residues of digestion:
trained in the toilet. – 100 ml/void) bile, intestinal
 The color is yellow secretions, shredded
PERSPIRATION without epithelial cells,
The patient perspires unpleasant odor bacteria, and
a lot due to hot  There’s no inorganic material
climate especially at phenomenon of (chiefly calcium and
noon time. dysuria phosphates); seeds,
 Urinary control is meat fibers, and fat
exhibited may be present in
small amounts
PERSPIRATION
 The patient Source:
experiences Taylor, Carol et al.,
perspiration Fundamentals of
during the Nursing: The Art and
elevation of body Science of Nursing
temperature Care, 5th edition.
above normal Lippincott Williams
even though the and Wilkins 2005.
room where she p.1346
stays is air-
conditioned. Normal
Characteristics of
Urine
Color – a freshly
voided specimen is
pale, yellow, straw-
colored, or amber,
depending on its
concentration.
Odor – normal urine
smell is aromatic. As
urine stands, it often
develops an ammonia
odor because of
bacterial action
Turbidity – fresh urine
should be clear or
translucent as urine
stands and cools, it
becomes cloudy
pH – the normal pH is
about 6.0, with a
range of 4.6 to 8
Specific Gravity –
1.010 to 1.025
Constituents –
Organic constituents
of urine include urea,
uric acid, creatinine,
hippuric acid,
indicant, urine
pigments, and
undetermined
nitrogen. Inorganic
constituents are
ammonia, sodium,
chloride, traces of
iron, phosphorus,
sulphur, potassium,
and calcium
Source:
Taylor, Carol et al.
Fundamentals of
Nursing: The Art and
Science of Nursing
Care, 5th edition.
Lippincott Williams
and Wilkins 2005.
p.1297
Interpretation:
The elimination
pattern (before and
during
hospitalization) has
points of deviation
from normal. The
patient’s urine output
during the hospital
stay is not sufficient
(should be about 500
to 600 ml) wherein
she’s not abiding with
the order of
increasing her fluid
intake. On the other
hand, she perspires
excessively during
hospitalization which
can probably lead to
dehydration if no
proper intervention
will be done. The
parents should
encourage their child
to comply with an
increased fluid intake
to restore adequate
level of hydration.

The toddler is full of  The patient is
energy and has an deprived of Analysis:
overwhelmingly physical activities
intense desire to that promotes Walking involves a
move around and skeletal muscle wide stance and
explore her contractions due unsteady gait, thus
environment. She to her condition the term toddler.
doesn’t have a From ages 1 to 5
planned and  The patient is in years, both gross and
structured form of ambulation which fine motor skills are
exercises behind the means she can refined. For example,
reason that it’s still just walk at least by 3 years of age is
beyond her going to the the toddler able to do
consciousness as a comfort room the following?
EXERCISE child. But she engages  Walk up steps
 Although she’s
in physical activities without assistance
under complete
that she doesn’t know
bed rest, she can  Balance on one
are already foot, jump, and
still practice ROM
considered as walk on toes
exercises that she
exercises. Her mother
does unnoticed  Copy a circle
flexion/  Build a bridge
said that she plays
e.g.
almost everyday from blocks
extension of
particularly in the
arms/legs,  Ride a 3-wheeled
afternoon. She loves bike
abduction/
to push and pull toys
adduction of the Immobility can impair
(toy cars to be
arms/legs which the social and motor
specific). She rides in
can be observed development of
a small bike around
when she eats young children.
their house. She’s not
and goes to the
placid and sedentary Source:
C.R.
rather she’s very Kouzier, Barbara et
active most of the al. Fundamentals of
time. Nursing: Concepts,
Process, and Practice,
8th edition, Volume 2
©2008. Pearson
Education, Inc., p. 377
and p. 1116
Interpretation:
The patient can still

continue her need for
physical activity in the
hospital because
she’s only ambulatory
not immobile,
capable of walking
without assistance at
times but with the
help of her parents
sometimes when
she’s experiencing
weakness. She’s not
immobile which
means she can still
perform a number of
ROM (range-of-
motion exercises)
maintaining her
muscle tone and
developing her motor
skill as part of a
child’s development.
The patient takes a  The patient
bath 2x a day (day cannot Analysis:
and night). The perpetuate her
mother doesn’t needs for self-care The time for a
ensure a diet because of her toddler’s bath should
appropriate for her condition. She depend on the
toddler, which can seldom brushes parents’ and the
actually contribute to her teeth behind child’s wishes and
clean and intact skin. the fact that her schedule. Some
The patient’s oral gumas and lips are parents prefer to
hygiene practice becoming dried. bathe a toddler
includes brushing her As a substitute for before the evening
teeth twice a day only full bath, her meal because it has a
not visiting the mother applies a quieting effect and
dentist at least once tepid sponge bath prepares a child for
HYGIENE per annum. In terms for her child as a eating; others prefer
of grooming, the directive of the to give it at bedtime
mother makes sure attending because it has a
that the hair of her physician to lower relaxing effect and
daughter is always the body helps the child sleep.
kept clean, combed, temperature. The time, however, is
and brushed not as important as
regularly. She also the attempt to
cleans the nails of her establish a sense of
child and cut them at routine, a sense that
an appropriate life has order.
length. To maintain
the patient’s skin Source:
complexion, the Pillitteri, Adele.
mother applies baby Maternal and Child
lotion at night after Health Nursing: Care
taking a bath and of the Childbearing
before her child goes and Childrearing
th
to sleep. The mother Family, 5 Edition ©
puts baby powder at 2007. Philadelphia,
times to the child’s USA Lippincott
back. The toddler Williams & Wilkins, p.
doesn’t have deep 874
appreciation between
hygiene and over-all
well-being for she’s
still in the process of
acquisition of the Interpretation:
significance of
personal hygiene. The The patient’s hygienic
child’s hygienic pattern falls within a
preferences are often normal scale
followed by her (appropriate for a
mother. toddler). There are
deviations from
standard due to
hospitalization and to
her skin condition
(turgor and dry lips).
After discharge, the
patient should
recuperate a good
personal hygiene as
similar from her
hygiene before she
was hospitalized.
ACTIVITIES OF BEFORE HOSPITALIZATION DURING ANALYSIS AND
DAILY LIVING HOSPITALIZATION INTERPRETATION
The mother verbalized,  The patient
“Pinapainom ko siya ng vitamis only takes the Analysis:
gaya ng Ceelin (Vitamin C) at medications
Nutrillin (Multivitamins). prescribed by Substance use
Kapag nilalagnat siya, the attending especially intake of
pinapainom ko ng Tempra physician beneficial
(Paracetamol).” The family of whether thru IV substances can be
the child adheres to self- or by mouth. imperative for a
medication. When the patient better health if
is at the onset of cough and taken under
colds, the mother lets her child moderation and
take more so, with a
Neozep(Phenylpropanolamine doctor’s consent
SUBSTANCE ) or Solmux (Carbocisteine) but when elevated
USE to an abused state
has come to refer
to overindulgence
in and dependence
on a chemical
leading to effects
that are
detrimental to the
individual’s
physical and
mental health, or
the welfare of
others.
Source:
Case Study by
Melencio, John
Alex, Miane,
Jomarlo, et al
under the
supervision of
Marilou Choa,
MAN, RN.
Interpretation:
The patient is not

going through any
kind of substance
abuse. Her parents
should be notified
regarding the right
medications that
their child must
take if for an
instance, the
toddler has a
pathologic disease
not just mere
symptom
(cough/colds).
They should learn
the importance of
interventions by
health care
workers e.g.
medical doctor in
terms of health
restoration.
According to the  Sexual
mother, the patient expressions are Analysis:
has become more not exhibited e.g.
curious about her exploring the Both mothers and
own body when she genitals when fathers should cuddle
turned to be a toddler there’s bowel and touch babies.
than when she was an movement or During the child’s first
infant. “Minsan nga urination. three years, he or she
tinatanong niya kung Nonetheless, the is learning what it
babae daw ba siya”, patient is still a means to be a boy or
the mother alleged. toddler so she a girl. Give your child
This statement gives doesn’t have the the opportunity to
evidence to the urge or the idea explore a range of
increased awareness about the roles and activities
of the child of her sex. consequent that are not restricted
The father further outcome of doing by barriers that say
SEXUALITY added, “Naglalaro such act. “little girls do this,”
siya ng kotse- and “little boys don’t
kotsehan at espa- do that.” Your child is
espada (toys) minsan learning about caring
kasama mga kalaro for others, sensitivity
niya. Puro lalaki kasi to feelings and solving
ang mga kalaro.” This problems.
discourse illustrates
the child’s imitation Source:
of the behaviour of Hickling, Meg.
the common people Speaking of Sex: Are
(playmates) who You Ready to Answer
usually engages with the Questions Your
her during playtime. Kids Will Ask?. British
Columbia: Northstone
Publishing 1996
Interpretation:
The child’s sexuality
pattern is customary
in toddlerhood. To
manage the patient’s
gender identity and
gender role, the
parents should start
orienting their
offspring about the
ways of living a girl
pursues, how she
acts, behaves or
thinks. In this case,
she’s readily in
touched with boys so
the parents must
conduct regular talks
with their child
regarding the
qualities of being a
girl in order to
achieve the
appropriate gender
and roles that she
should develop.
The patient’s mother  The father said,
said that her child “Paputul-putol Analysis:
usually sleeps 12 ang tulog niya
hours on a daily basis. (patient) kasi Between 12 and 14
Nevertheless, the lagging may hours of sleep are
toddler takes some pumupunta na recommended for
naps during the day tumitingin ng children 1 to 3 years
averaging 2 naps. temperature of age. Most still need
Although at times, niya.” Even if the an afternoon nap, but
noises are around, patient’ sleep is they need for
she settles better if hindered most of midmorning naps
the environment is the time in her gradually decreases.
quiet and when she stay in the The toddler may
places her body in a hospital, she exhibit a great deal of
blanket. She has no tends to sleep and resistance to going to
sleeping problems. rest as her bed and may awaken
No interference is pastime. The during the night. A
SLEEP observed. The mother parents perceive security object such
AND described their home that their child as a blanket or stuffed
setting as conducive still feels good as animal may help.
REST
for sleeping. if she really sleeps Sleep and rest are
adequately. vital for optimal
psychological and
physiological
functioning.
Source:
Kouzier, Barbara, et
al. Fundamentals of
Nursing: Concepts,
Process, and Practice,
8th Edition. Pearson
Education, Inc. ©
2007, p. 1167
(modified)
Interpretation:
The patient’s sleep
and rest in her daily
routine are
considered sufficient
for her age. With the
aim of promoting a
good sleeping
environment, the
parents can learn to
comfort their child,
keeping the lights low
and using as soft
voice and as much as
possible overcome
the sound
interference in the
surrounding.
VI. PHYSICAL ASSESSMENT
V. PHYSICAL ASSESSMENT
Vital Signs: Actual Finding Normal Finding Analysis and Interpretation
Normal body
temperature ranges
from 36.50C up to
37.50C or 96.8 - 98.60F
and normally deviates
1.Temperature 39.80C higher or lower in Abnormal. It indicates
some points pyrexia/hyperthermia/
depending on fever
environmental
condition and activity.
Kozier and Erb’s (2008)
Fundamentals of Nursing 8th Edition:
published by Pearson Education. Inc.
p.534
2. Pulse Rate Pulse rate of a

toddler is ranging
from 80-140 bpm
Taylor (2005) Fundamentals of
110 Normal
Nursing 5th Edition: published by
Lippincott Williams and Wilkins.
p.525
3. Respiratory Rate Respiratory rate of an

adult is ranging from Normal
32 20 -40 bpm
Taylor (2005), Fundamentals of
Nursing 5th edition p.525
4. Blood Pressure Blood pressure of an

adult is 90/55 but it Normal
90/60 can also vary
individually
Carol Taylor, Fundamentals of Nursing
5th edition p.525
PART 1:
Body Part Actual Findings Norms and Standards Analysis
1.Height 4’11 According to the Body

Mass Index (BMI)
Chart, BMI of 18.6-
22.9 is normal, <18.5
is underweight, > or =
2. Weight 12.7 kg
to 23 is overweight
(DOH book p. 202)
GENERAL SURVEY:
1. Body built in relation

to age, lifestyle and Proportionate, varies
health. Client’s body built is with lifestyle
Kozier and Erb’s (2008) Fundamentals
not appropriate for Abnormal. It
of Nursing 8th Edition: published by
her age indicates lack of
Pearson Education. Inc. p.572
nutrition.
2. Posture and gait,

standing, sitting and Always sleeping and Relaxed, erect posture
walking. restless and coordinated
movements Abnormal. It implies
an illness state
(lethargy).
3. Overall hygiene and Clean, neat

grooming. Clean and Neat Normal
4. Body and breath No body and breath No body and breath

odor. odor odor relative to work Normal
or exercise; no breath
odor
5. Signs of distress in No distress noted No distress noted

posture or facial Normal
expression.
6. Obvious sign of
health and illness. Weakness noted Healthy appearance
Abnormal. It denotes
an illness state.
7. Client’s attitude.
Cooperative and able
to follow instructions Abnormal. It points
Not Cooperative out her irritability to
sickness.
8. Note client’s
affect/mood; Appropriate to the Respond
appropriateness of the situation appropriately to the Normal
response. situation
9. Quantity and quality

of speech. Understandable,
moderate pace; clear
Understandable tone and inflection; Normal
exhibits thought
association
10. Relevance and

organization of Logical sequence;
thoughts. makes sense; has Normal
Makes sense sense of reality
SKIN:
1. Color, uniformity of
color and appearance. Varies from light to
Brown skin tone with deep brown; from
rashes on the back of ruddy pink to light Abnormal. It suggests
the body pink; from yellow a sign of hemorrhagic
overtones to olive. fever(petechiae).
Generally uniform
except in areas
exposed.
2. Presence of edema.
No edema Normal
No edema
3. Skin lesions,
according to location, Freckles, some
distribution, birthmarks, some flat
configuration, size, No lesions or skin and raised nevi; no Normal
shape, type or abrasions abrasions or other
structure. lesions
4. Skin temperature. Uniform within

Generalized hot normal range
temperature Abnormal. It signifies
generalized
hyperthermia/fever.
5. Skin turgor.
Skin moved back When pinched, skin Abnormal. It may
slowly when pinched springs back to indicate dehydration
previous state or deficient in body
fluids.
Pearson Education. Inc.
p.579
NAILS:
1. Plate shape, Convex curvature Convex curvature

curvature and angle. with an estimated with an estimated
angle of about 160 angle of about 160 Normal
degrees. degrees.
Long clean nails.
2. Fingernails and toe Highly vascular and

nail bed colored. pink in light-skinned;
Pink in color dark skinned clients Normal
vascular may have black
pigmentation in
longitudinal streaks.
3.Nail Texture Smooth texture


Smooth Normal
4. Tissues surrounding Intact epidermis

the nails. Intact epidermis Normal
5. Blanch test of Prompt return of

capillary refill. Nail color readily punk or usual color Normal
returns when (generally less than 4
pinched. seconds).
HEAD
SKULL:
1.Size, shape, and Rounded,

symmetry of the skull Rounded, symmetrical, smooth
symmetrical, smooth skull contour, no Normal
skull contour, no extra prominences.
extra prominences.
2. Nodules, masses, Smooth, uniform in

and depressions. consistency, absence
Smooth, no nodules of nodules or masses. Normal
or masses.
SCALP:
1. Color and No depressions;

appearance. smooth; inelastic;
No depressions, white with even coloration. Normal
in color, no visible
dandruff flakes.
2. Areas of No tenderness noted No tenderness Normal

tenderness.
HAIR:
1. Evenness of Evenly distributed
growth, thickness or hair, thick hair.
thinness over the Hair is evenly Normal
scalp. distributed and thick.
2. Hair texture, color Hair is straight, no Silky, resilient hair; no Normal

and oiliness. infection or infection or
infestation noted. infestation.
FACE:
1. Facial features and Symmetric or slightly

symmetry of facial Symmetrical facial asymmetric facial
movement. features and features; palpebral Normal
coordinated facial fissures equal in size;
muscle movement. asymmetric nasolabial
folds.
EYES
EYEBROWS:
1. Hair distribution, Hair evenly

alignment, quality Hair evenly distributed; skin Normal
movement. distributed and intact; eyebrows
symmetrically aligned symmetrically
with equal aligned; equal
movement. movement.

EYELASHES:
1. Evenness of Equal distribution;

distribution and Equal distribution; curls slightly outward. Normal
direction of curl. slightly thin lashes;
curls slightly outward.
EYELIDS:
1. Surface Skin is intact and Ski is intact; no Normal

characteristics, closes symmetrically. discoloration; no
position in relation to discharges; lids close
the cornea, ability to Involuntary blink symmetrically.
blink, frequency of present about 12 Approximately 15-20
blinking. times in a minute. involuntary blinks per
minute; bilateral
blinking when lids are
open, no visible sclera
above corneas are
slightly covered.
CONJUNCTIVA:
1.Color, texture, and Transparent and

presence of lesions in Transparent and capillaries sometimes Normal
the Bulbar capillaries are evident; sclera
conjunctiva prominent. appears white
(yellowish in dark-
skinned clients).
2. Color, texture, Shiny, smooth and

presence of lesions on Shiny and smooth, pink to red in color. Normal
the palpebral pale red.
conjunctiva.
SCLERA:
1.Color and clarity White in color. White. Normal

CORNEA:
1.Clarity and texture Transparent, smooth,

Transparent, smooth, shiny; details of iris Normal
shiny; when the client are visible. Client
blinks, the cornea is blinks, the cornea is
touched. touched, indicating
that the trigeminal
nerve is intact.
IRIS:
1.Color and shape Color varies, oval and

Dark brown in color, flat Normal
oval
PUPILS:
1.Color,shape, Black in color;

symmetry Black in color; smooth normally 3-7 mm in Normal
and round diameter, round,
smooth borders.
2. Light reaction and Illuminated and non- Illuminated and non- Normal
accommodation. illuminated pupil illuminated pupil
constricts. constricts.
Color black and both
eyes are with the
same equally rounded
structure.
VISUAL ACUITY:
1.Near vision Client can read Able to read Normal

newsprint. newsprint.
2.Distant vision Client can see far 20/20 on the Snellen Normal
objects chart
LACRIMAL GLAND, LACRIMAL SAC, NASOLACRIMAL DUCT:
1. Inspect and palpate No edema or tearing

the lacrimal gland and No edema or tearing Normal
duct.
EXTRAOCULAR MUSCLES:
1.Eye alignment and Eyes are coordinated, Alignment Normal

coordination aligned and parallel
with each other.
VISUAL FIELDS:
1.Peripheral vision Client can see objects When looking straight Normal
in periphery. ahead, client can see
objects in periphery.
EARS
AURICLES:
1. Color, symmetry Color is the same with

and position. Color is the same with the skin in the face; Normal
the skin in the face; auricle aligned with
symmetrical and the outer canthus of
aligned with the eyes. the eye, about 10
degrees from vertical.
2. Texture, Elasticity Movable, firm and

and areas for Movable, firm, recoils not tender, pinna Normal
tenderness. readily when recoils after it is
distorted. folded.
EXTERNAL EAR CANAL:

1. Cerumen, presence Ear wax, no lesions,
of skin lesions, pus or With ear wax or pus or blood. Normal
blood. cerumen; no
presence of pus or
blood.
NOSE:
1. Shape, size, color, Symmetric, straight,

flaring, or discharge. Symmetric, straight, uniform in color, no Normal
uniform in color discharges or flaring.
2. Presence of Pink mucosa, clear,

redness, swelling, Mucosa is pink; no watery discharge; no Normal
growths or discharge redness or swelling; lesions.
of the Nasal Cavities. no presence of
lesions.
3. Nasal Septum. Intact and aligned Nasal septum is intact

medially and aligned medially Normal
4.Patency test or the Air exchanges with Air moves freely as

nasal cavities ease. the client breathes Normal
through the nares.
5. Tenderness, No tenderness and No tenderness and

masses, displacement displacement displacement. Normal
of the bone and
cartilage.
SINUSES:
1.Tenderness No tenderness Not tender. Normal

SINUSES (front and maxillary)

1. Tenderness No tenderness No tenderness noted on Normal
palpation.
(www.nursingcrib.com)
MOUTH
I. Lips:
1. Symmetry, color, Symmetrical, • Symmetry in contour Abnormal. Dry
contour and texture uniform pinkish • Uniform pinkish lips indicate
to brown in color, • Moist lips fluid deficit.
dry lips, smooth • Smooth
(Kozier, Barbara(2002),
Fundamentals of Nursing
5th edition: Addison-
Wesley Publishing
Company, p.499)
II. Buccal Mucosa:
1. Color, Moisture, Pinkish color, soft • Uniform in color Normal
Texture and presence of and moist • Soft and moist
lesions • Smooth and elastic
texture
Wesley Publishing
Company, p.499)
III. Teeth:
1. Color, number, 20 teeth, smooth, • 20 primary teeth Normal

condition, presence of white • Smooth
dentures • Shiny tooth enamel
• Smooth and intact
dentures
(http://www.colgate.com)
2. Color and condition Pink gums, moist, • Pink gums Normal
of gums firm • Moist
• Firm texture to gums
• No retraction of gums
Wesley Publishing
Company, p.499)
IV. Tongue:
1. Color and texture of Reddish color, • Smooth tongue base Normal
mouth floor and veins prominent, with prominent veins
frenulum and smooth (Kozier, Barbara(2002),
texture Fundamentals of Nursing
Wesley Publishing
Company, p.501)
2. Position, color, Tongue is located • Central position Normal
texture, movement and at the center, • Pink color
check the base of the pink color, moist, • Moist
tongue papillae • Slightly rough
prominent and • Thin whitish coating
moves freely • Smooth lateral margins
• No lesions
• Raised papillae
• Moves freely
• No tenderness
Wesley Publishing
Company, p.501)
3. Presence of nodules, No tenderness, • Smooth with no Normal
lumps or excoriated no palpable palpable nodules
areas nodule or lumps (Kozier, Barbara(2002),
Wesley Publishing
Company, p.501)
V. Palates and Uvula:
1. Color, shape, texture Soft palate is pale, • Pink color Normal
and presence of bony pink in color, • Moist
prominence smooth while • Soft palate
hard palate is • Light pink hard palate
pink in color and • More regular texture
normal texture (Kozier, Barbara(2002),
Wesley Publishing
Company, p.502)
2. Position and mobility Medially aligned • Position in midline of Normal
of uvula soft palate
Wesley Publishing
Company, p.502)
VI. Oropharynx and Tonsils

1. Color and texture Pink and smooth • Pink and smooth Normal
posterior wall
2. Size, color and No • Pink Normal
discharge tonsipharyngeal • Smooth
congestion • No discharge
NECK
I. Lymph Nodes:
1. Tenderness No tenderness • No tenderness Normal
Wesley Publishing
Company, p.505)
II. Trachea:
1. Placement Midmost with • Central placement in Normal
equal spaces on the midline of the neck
both sides • Spaces are equal in both
sides
Wesley Publishing
Company, p.506)
III. Thyroid Glands
1. Inspect for symmetry No visible masses • Not visible in inspection Normal
and visible masses (Kozier, Barbara(2002),
Wesley Publishing
Company, p.506)
2. Smoothness and No engorgement • Lobes may be not Normal
areas of enlargements palpated. If palpated
lobes are small, smooth
and rise freely when
swallowing.
Wesley Publishing
Company, p.507)
Body part Actual findings Norms and Standards Analysis and
Interpretation
THORAX:
I. Posterior Thorax:
1. Shape, symmetry, Transverse • Anteroposterior to Normal
diameter of anterior diameter is twice transverse diameter is in
thorax to transverse the ratio of 1.2
diameter anteroposterior • Chest symmetric
diameter, (Kozier, Barbara(2002),
symmetrical, Fundamentals of Nursing
intact skin 5th edition: Addison-
Wesley Publishing
Company, p.513)
2. Spinal alignment Spine is aligned • Spine is vertically Normal
aligned
Wesley Publishing
Company, p.513)
3. Temperature, Uniform in • Uniform in temperature Normal
tenderness and masses temperature, • No tenderness
absence of • No masses
tenderness and (Kozier, Barbara(2002),
masses Fundamentals of Nursing
Wesley Publishing
Company, p.513)
4. Respiratory excursion Symmetrical • Full and chest expansion Normal
chest expansion, (Kozier, Barbara(2002),
the thumbs move Fundamentals of Nursing
apart an equal 5th edition: Addison-
distance during Wesley Publishing
assessment Company, p.514)
5. Vocal fremitus Symmetrical in • Bilateral symmetry of Normal
both sides vocal fremitus
• Fremitus is most clearly
heard at the apex of the
lungs
Wesley Publishing
Company, p.514)
6. Percussion Resonance except • Percussion notes Normal
in the scapulae resonate, except over the
scapula. Lowest point of
resonance is at the
diaphragm
Wesley Publishing
Company, p.515)
7. Auscultation Clear breath • Clear breaths sound Normal
sounds (Kozier, Barbara(2002),
Wesley Publishing
Company, p.516)
II. Anterior Thorax
1. Breathing patterns Effortless • Quiet Normal
respiration • Rhytmic and effortless
respirations
Wesley Publishing
Company, p.447)
2. Temperature, Uniform in • Uniform in temperature Normal
tenderness and masses temperature with • No tenderness
no tenderness • No masses
/masses (Kozier, Barbara(2002),
Wesley Publishing
Company, p.513)
3. Auscultation of the Loud bronchial • Bronchial sound is houd, Normal
trachea sound and long “harsh” sounds that has
phase of short inspiratory phase
expiration (Kozier, Barbara(2002),
Wesley Publishing
Company, p.517)
4. Auscultation of the Vesicular sounds • Vesicular sound has soft Normal
anterior thorax heard at intensity, low pitched,
inspiration, “gentle sighing” and is
bronchovesicular best heard on inspiration
sounds heard in which about 2.5 times
both expiration longer than expiratory
and inspiration phase
• Bronchovesicular sound
is moderate-pitched
“blowing” sound and has
equal inspiratory and
expiratory phases
Wesley Publishing
Company, p.518)
CARDIOVASCULAR
I. Carotid Arteries:
1. Palpation of the Symmetric pulse • Symmetric pulse Normal
carotid artery volumes
• Full pulsations
• Thrusting quality
Wesley Publishing
Company, p.523)
2. Auscultation of the No heard • No sound heard on Normal
carotid artery pulsations auscultation
Wesley Publishing
Company, p.524)
II. Jugular Veins:
1. Inspection of the Not visible  No visible mass or Normal
jugular veins lumps.
 Symmetrical
 No jugular venous
distension
BREAST AND AXILLAE
1. Size, symmetry, Symmetrical • Females: rounded Normal
contour, and shape contour, no shape, slightly unequal in
dimpling size, generally symmetric
Wesley Publishing
Company, p.529)
2. Skin of the breast Uniform in color, • Skin uniform in color, Normal
smooth and intact smooth and intact
Wesley Publishing
Company, p.529)
3. Size, shape, position, Round and the • Rounded or oval, with Normal
color, surface, same on both same color, (Color varies
characteristics and any sides, light pink, from light pink to dark
mass or lesions of the no mass or brown depending on
areola lesions race).
4. Size, shape, position, No abnormal • Rounded, everted, same Normal
color, discharge, and nipple discharge size and equal in color
lesions of the nipples • No discharge except for
breastfeeding females
5. Palpation of breast No palpable mass, • No lumps or masses are Normal
for masses and no tenderness palpable.
tenderness •No tenderness upon
palpation.
•No discharges from the
nipples.
ABDOMEN
1. Skin integrity No blemishes, • Unblemished skin, Normal
uniform in color, uniform in color
with abdominal (Kozier, Barbara(2002),
incision brought Fundamentals of Nursing
by surgery 5th edition: Addison-
Wesley Publishing
Company, p.534)
2. Abdominal contour Slight globular • Contour (flat, rounded, Normal
abdomen scapoid)
3. Enlargement of the Absent • No evidence of enlarge Normal
liver or spleen (Kozier, Barbara(2002),
Wesley Publishing
Company, p.534)
4. Symmetry of contour Symmetric • Symmetric contour Normal
Wesley Publishing
Company, p.535)
5. Abdominal Symmetric • Symmetric movements Normal
movements associated caused by respiration
with respirations, • Visible peristalsis in very
peristalsis or aortic lean people
pulsations • Aortic pulsation in thin
persons at epigastric area
Wesley Publishing
Company, p.535)
6. Vascular patterns No visible pattern • No visible vascular Normal
pattern
Wesley Publishing
Company, p.533)
7. Bowel sounds, Audible bowel • Audible bowel sounds Normal
vascular sounds, sounds, no bruits • Absence of arterial
peritoneal friction rubs present bruits
of abdomen (Kozier, Barbara(2002),
Wesley Publishing
Company, p.535)
8. Percussion of each Tympanic in the • Tympany over the Normal

abdominal quadrant stomach area, stomach and gas-filled
dull over the bowels, dullness
organs especially over the liver
and spleen or full bladder
Wesley Publishing
Company, p.533)
9. Palpation of all four No tenderness, • No tenderness, relaxed Normal
quadrants abdomen is abdomen with smooth
relaxed without consistent tension
intense tension (Kozier, Barbara(2002),
Wesley Publishing
Company, p.535)
MUSCULOSKELETAL SYSTEM
Muscles:
1. Muscle size and Equal size on both • Equal size on both side Normal
symmetry (arm, thigh, sides and of the body
calf) symmetrical (Kozier, Barbara(2002),
Wesley Publishing
Company, p.540)
2. Contractures of Absent • No contractures Normal
muscles or tendons (Kozier, Barbara(2002),
Wesley Publishing
Company, p.540)
3. Muscle fasciculation Absent • No muscle fasciculation Normal
or tremors or tremors
Wesley Publishing
Company, p.540)
4. Tonicity of muscles Firm • Normally firm Normal
Wesley Publishing
Company, p.541)
5. Strengths of muscles Symmetrical on • Equal strengths of both Normal
both sides sides of the body
Wesley Publishing
Company, p.541)
Bones:
1. Normal structures No deformities • No deformities Normal
and deformities (Kozier, Barbara(2002),
Wesley Publishing
Company, p.541)
2. Presence of edema or No edema • No tenderness or Normal
tenderness swelling
Wesley Publishing
Company, p.541)
Joints:
1. Presence of joint None • No swelling Normal
swelling (Kozier, Barbara(2002),
Wesley Publishing
Company, p.542)
2. Palpation for Absence of • No tenderness, swelling Normal
tenderness, smoothness tenderness, or crepitation or presence
of movement of swelling or of nodules
movement, swelling, crepitation or • joints move smoothly
crepitation and presence of (Kozier, Barbara(2002),
presence of nodules nodules, Fundamentals of Nursing
Wesley Publishing
Company, p.542)
Assess Range of motion:

Upper Extremities:
1. Shoulder and scapula Movable within • Varies in accordance Normal
2. Elbows range of motion with the person’s genetic
3. Hands make up and degree of
physical activity
Wesley Publishing
Company, p.542)
Lower Extremities:
1. Acetabulum or Movable within • Varies in accordance Normal
inguinal area range of motion with the person’s genetic
2. Popliteal make up and degree of
3. Ankles physical activity
Wesley Publishing
Company, p.542)
VII. LABORATORY AND DIAGNOSTIC EXAMINATION RESULTS
VI. LABORATORY AND DIAGNOSTIC EXAMINATIONS
URINALYSIS
Macroscopic (Physical Examination and Chemical Screening)
Results Normal Values Analysis and Interpretation
Color Yellow Straw to dark Normal

yellow
Character Hazy Urine is normally Normal

transparent
ph 6.0 4.6 – 6.5 Normal
Protein (-) None Normal
Specific Gravity 1.030 1.016 – 1.022 Increased.
Bilirubin (-) Normally bilirubin Normal

is present in such
small quantities in
the urine that is
not detected by
routine screening
procedures.
Urobilinogen Normal 0.3-1.0 Erlich units Normal- Urobilinogen is

in a 2 hr sample formed in the intestine
(1-3pm) from the conjugated
bilirubin normally present
0.5-4.0 Erlich units
in bile salts. Most of
in a 24 hours
urobilinogen is excreted in
sample (0.4-
feces, but a small amount
1mg/day)
that finds its way into the
bloodstream either goes
through the liver again or is
excreted in the urine.
Urinary urobilinogen can be
used to detect early liver
dysfunction. The amount of
urinary urobilinogen
decreases when there is a
lack of intestinal flora to
convert bilirubin to
urobilinogen.
Nitrite (-) Should be Normal- Most species of

Negative bacteria, such as
Enterobacteriaceae, if
present in the urine, cause
the conversion of nitrates,
which are derived from
dietary metabolites to
nitrites. A negative nitrite
test result does not provide
sufficient proof of no
bacteria, as some bacteria
do not produce nitrates.
Blood (-) 0 Elevated-Bloody urine can

be a sign of bleeding in the
genitourinary tract as a
result of systemic bleeding
disorders, various kidney
diseases, bacterial
infections, parasitic
infections including malaria,
obstructions in the urinary
tract, scurvy, sub-acute
bacterial endocarditis,
traumatic injuries and
tumor.
Ketones (-) Normally urine Normal-Ketones are

should not contain metabolic end products of
enough ketones to fatty acid metabolism.
give a positive When the body does not
reading have sufficient glucose to
use for energy, the
excretion of ketones
increases. The presence of
ketones in the urine
signifies that the body is
using fat as the major
source of energy. Fats are
used when glucose is
unavailable to the cells.
Glucose (-) Usually negative; Normal - Glucose in the

may be trace in urine signifies either (1)
normal pregnancy. hyperglycermia or (2) a
Lactosuria is decreased renal threshold
common in the for glucose. The renal
last trimester. threshold for glucose is
usually about 160-190 mg/
100ml of blood; in other
words, no sugar is spilled
into the urine until the
blood sugar rises above this
level.
Leukocytes +1 Should be Abnormal- The LE

negative (leukocyte esterase) test
identifies enzymes found in
granulocytes, histiocytes,
and Trichomonas. It also
should detect both lysed
and intact cells which it did
not.
HEMATOLOGY
Result Result Result Result Norma Interpretation

(08/02 s s s l Analysis
/09 (08/04 (08/06 (08/07 Values
/09) /09) /09)
RBC 4.76 x 4.25 x 4.5-5.5 Normal-If it was

10¹²/L 10¹²/L x low it can result
10¹²/L from: Abnormal
loss of
erythrocytes,
Abnormal
destruction of
erythrocytes, lack
of needed
elements or
hormones of
erythrocytes
production and
bone marrow
suppression.
Hemo 11.80 10.80 12.70 11.60 12-14 Decreased-

globin g/dl g/dl g/dl g/dl g/dl Hemoglobin is
composed of a
pigment (heme),
which contains
iron, and a
protein part
(globin). Because
hgb is a
component of the
red blood cell, all
the conditions
that cause a low
RBC naturally
result in a low
hgb level too.
Some of the
common
conditions for a
low RBC would be
blood loss,
haemolytic
anemias and any
type of bone
marrow
suppression.
Hema 0.36 0.32 0.38 0.37 0.37- Decreased-The

tocrit L/L L/L L/L L/L 0.45L/ hematocrit is a
L fast way to
determine the
percentage of red
blood cells in the
plasma. A
decreased hct can
be due either (1)
an over hydration
of the patient,
which increases
the plasma
volume or (2) a
true decrease in
the number of
the red blood
cells.
Platel 257 x 100 x 78 x 73 x 160- Normal-

et 10⁹⁄L 10⁹⁄L 10⁹⁄L 10⁹⁄L 380 x Sometimes
Count 10⁹/L platelets are
considered as a
third type of
blood cell in the
plasma. Actually,
platelets are not
intact cells but
only fragments of
cytoplasm whose
only role seems
to be in the blood
coagulation
process.
MCV 74.6 fl 75.0 fl 82-92 The MCV is an

fl indicator of the
size of red blood
cells. If the MCV is
lower than 86
µm3, the
erythrocytes are
microcytic or
smaller than
normal. Red
blood cells are
microcytic in
certain types of
anemia such as
iron deficiency
anemia and lead
poisoning.
MCH 24.8 25.4 27-33 Decreased-The
pg pg pg MCH is the
amount of hgb
present in a single
cell. The result is
reported by
weight in
pictograms. The
weight of hgb in
the average cell is
obtained by
divided by the
hgb by RBC.
MCHC 33.2% 33.9% 32- Decreased in hgb

38% concentration
(hypochromic). To
get the
percentage, the
hgb is divided by
the hct and
multiplied by 100.
MCH=hgb(g/100
ml) x 100 divided
by hct
WBC 3.78 x 2.46 x 5.0- Decreased-WBC is

10¹²/L 10¹²/L 10.0 x an absolute
(smok 10¹²/L number of so
ers many thousand
tend white blood cells
to per cubic
have millimetre, with a
higher neutrophil count
rate) of 60% and a
lymphocyte count
of 30%.
Differential- is the determination of the proportion of each of the five types of white blood
cells in sample of 100 white blood cells.
Eosinophils 0.01 0.03-0.05 Decreased- The actual

function of eosinophils is
not clearly understood, but
they are associated with
antigen-antibody reactions.
The most common reasons
for an increase in
eosinophils (eosinophilia)
are allergic reactions such
as asthma, hay fever or
hypersensitivity to drug.
Parasitic infestations, such
as round warms, are
another reason for an
eosinophil increase. Other
conditions in which
eosinphils increase are
certain skin diseases and
neoplasms.
Segmenters 0.34 0.55-0.65 Decreased-Neutrophils,

classified as
polymorphonuclear
leukocytes (PMNs) seem to
be the body’s first defense
against bacterial infection
and severe stress. Normally
most of the circulating
neutrophils are in mature
from, which the
laboratories call mature
neutrophils segs or
segmented neutrophills.
Lymphocyte 0.44 0.25-0.35 Elevated-Lymphocytes are

the principal components of
the body’s immune system,
but only a small portion of
them circulate in the
bloodstream. In the
bloodstream, the majority
are T- lymphocytes (60-80-
%) rather than B
lymphocytes (5-15%) or non
B lymphocytes (10-20%).
This is due to viral infection.
Remarks: SGPT/ ALT: _________u/L
Normal Value: ______
Serum Glutamic- Pyruvic Transaminase (SGPT)/Alanine Aminotransferase (ALT)
Formerly known as SGPT, this transaminase is found in the largest concentration in liver tissue,
but it is also present in kidney, heart, and skeletal muscle tissue. Like the other transaminase
(AST or SGOT), ALT is increased in various types of tissue damage, and so it is not very specific.
ALT may be used if there is a specific need to evaluate the possibility of liver tissue necrosis or
liver damage from drugs. ALT has been seen as potentially useful in screening useful in
screening blood donors to reduce the incidence of non A- Non B hepatitis and its use has
reduced transfusion-borne hepatitis.
Interpretation and Analysis:
Increased SGPT/ALT-in severe hepatitis, the ALT is often greater than 1,000 IU and may rise to
4,000 IU. In chronic hepatitis and cirrhosis, the levels are not so markedly elevated. Infectious
mononucleosis, which often involves the liver, causes a significant rise in the ALT. Shock, Rye’s
syndrome, CHF, and eclampsia all cause an increased ALT because of some liver tissue damage.
SEROLOGY
Dengue blot IgG (-) IgM (+)
Remarks: Dengue NSI Antigent (-)
IgG- this immunoglobulin protects against viruses, bacteria, and toxins. It is more for a
secondary response. Thus specific IgG antibodies against infections indicate past esposure and
probable immunity.
IgM-is the major component in a primary immune response. IgM antibodies are indicators of an
active infection.
VIII. MEDICATIONS
IX. ANATOMY AND PATHOPHYSIOLOGY

X. ECOLOGIC MODEL
XI. PRIORITIZED LIST OF NURSING PROBLEMS
XII. NURSING CARE PLAN
XIII. DISCHARGE PLAN
DISCHARGE PLAN
M – edication
Intake of appropriate vitamin supplement and diuretics to increase protection mechanism of

the immune system and decreases renal vascular resistance and may increase renal blood flow,
respectively.
E – conomic
The use of nonpharmacotherapy such as drinking plenty of water will promote increase plasma
in blood to increase immunity and proper hygiene and promotion of cleanliness at home and
work area.
T – reatment
Management of such condition would be through hydration and doing control measures to
eliminate vector by promoting cleanliness in the environment through proper disposal of
rubber tires, changing of water of lower vases once a week, destruction of breeding places of
mosquito and residual spraying with insecticides.
H – ygiene
Advise to follow proper body hygiene and to maintain cleanliness on surroundings. This would
prevent additional cases of DHF.
O – ut Patient/ Follow-up
Any odd signs such as fever, petechiae, recurrence of fever,etc. must be immediately reported
to the physician.
D – iet
Instruct to eat foods that are low fat, low fiber, non-irritating and non-carbonated.
EVALUATION
CONCLUSION
The patient in this study had undergone supportive and symptomatic management. She was
admitted last September 20, and was transferred from Ward 1 to the Female Medical Ward last
September 23.
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
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.

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OBJECTIVES

 High fever, up to 105 degrees Fahrenheit

 Marked damage to blood and lymph vessels

This form of dengue disease can cause death.

 Fluids leaking outside of blood vessels

Address: 757 U. Soliven St., Brgy. Commonwealth, Quezon City

Age: 3 years old Gender: Female Religious Affiliation: Roman Catholic

Marital Status: Single

Room and Bed No.: 428A

Chief Complaint: Fever

Provisional Diagnosis: Dengue Hemorrhagic Fever I

Attending Physician: Dr. Candelaria

III. NURSING HISTORY

A. PAST HEALTH HISTORY

6. Medications used or currently taken

B. HISTORY OF PRESENT ILLNESS

2 days PTC - Patient started to have rashes after taking Cephalexin.

IV. PATTERNS OF FUNCTIONING

7. Family Coping Pattern

The cultural pattern of the client is focused on the development of a toddler as a

"Sapat naman ang kinikita naming mag-asawa para sa aming pang-araw-araw.

1. Religious Beliefs and Practices

The patient is a Jehovah’s witness, a restorationist, millenarian Christian denomination.

2. Values and Valuing

ACTIVITIES OF DAILY BEFORE DURING ANALYSIS AND

The patient’s diet

ACTIVITIES OF DAILY BEFORE DURING ANALYSIS AND

The patient can still

The patient is not

Vital Signs: Actual Finding Normal Finding Analysis and Interpretation

Fundamentals of Nursing 8th Edition:

published by Pearson Education. Inc.

2. Pulse Rate Pulse rate of a

Lippincott Williams and Wilkins.

3. Respiratory Rate Respiratory rate of an

Nursing 5th edition p.525

4. Blood Pressure Blood pressure of an

5th edition p.525

Body Part Actual Findings Norms and Standards Analysis

1.Height 4’11 According to the Body

1. Body built in relation

2. Posture and gait,

3. Overall hygiene and Clean, neat

Pearson Education. Inc. p.572

4. Body and breath No body and breath No body and breath

of Nursing 8th Edition: published by

Pearson Education. Inc. p.572

5. Signs of distress in No distress noted No distress noted

of Nursing 8th Edition: published by

Pearson Education. Inc. p.572

9. Quantity and quality

of Nursing 8th Edition: published by

Pearson Education. Inc. p.572

10. Relevance and

of Nursing 8th Edition: published by

Pearson Education. Inc. p.572

of Nursing 8th Edition: published by

Pearson Education. Inc. p.579

Pearson Education. Inc. p.579

of Nursing 8th Edition: published by

Pearson Education. Inc. p.579

4. Skin temperature. Uniform within

Pearson Education. Inc.