I.

HEALTH HISTORY
A. Demographic Data
1. Name:
2. Gender: Male
3. Age: 15
4. Birthdate: March 01, 1995
5. Address: 14146 Bancal, Carmona, Cavite
6. Citizenship: Filipino-Japanese
7. Religion: Catholic
8. Civil Status: Single
9. Occupation: None

B. Source and Reliability of Information

The informations we gathered are reliable because it is

shared by the patient’s SO and the patient himself.

C. Reason for Seeking Care or Chief Complaints

The patient’s chief complains is fever with a temperature of

40.7o C.
D. History of Present Illness

One day prior to admission, the patient started to

developed moderate to high grade fever associated with
headache and mild epigastric pain. There is no vomiting and
diarrhea noted. Prior to admission, the patient is awake,
coherent and weak looking. The patient is Not In Cardiac
Respiratory Distress (NICRD). The patient has pink
palpebral conjuctiva, hyperemic tonsils and positive to
petechial rahes. There is no cyanosis and edema noted. Full
and equal pulses are noted. His admitting vital signs are: T-
40.7o C., B.P.- 130
/80 mmHg, R.R.-20 cpm and P.R.-90 bpm.

E. Past Medical History

The patient was diagnosed with hypersensitivity to certain

meds especially penicillin. During his 11th year, he was
involved in an operation called Open Reduction Internal
Fixation (ORIF)
F. Family Genogram
 I. R.O.S. and P.E.

SYSTEM R.O.S. P.E.

General/ As verbalized by the  The patient is
Overall Health patient, “Ok naman po, conscious lying on bed
Status di naman ako in supine position
nanghihina.”  There is no body
weakness
 The patient is
afebrile
 No traces of
sweating or chills
 Able to understand
and reponse to the
question during
nurse-patient
interaction
Inregument As verbalized by the  Pallor skin, slightly
patient, “Ok naman, wala warm to touch when
naman kakaiba sa balat palpated
ko.”
Head and Hair “Di naman ako nahihilo” DURING INSPECTION:
as verbalized by the  The head is round
patient and symmetric.
 No lumps or lesion.
 No traces of
tenderness and
deformities.
 The hair is oily.
 Presence of scaly
scalp
 Nails “Hindi masakit” as  Good capillary refill
verbalized by the
patient

Eyes “Hindi naman nanlalabo  Eyelids close

ang paningin ko” as symmetrically.
verbalized by the  Iris- evident with
patient thin, brownish white
ring around the
margin
 Sclera- white
 Cornea- cotton wisp
Ears “Maayos naman,  Both ears are
nakakrinig naman ako” as symmetrical
verbalized by the  No redness or
patient discharge in ear canal
 No tenderness when
the auricles where
palpated.
 Slightly cold to touch
Nose/Sinuses “Hindi naman barado” as  Symmetric in shape
verbalized by the  No discharge, lesion
patient or nodules
Mouth and “Maayos naman panlasa  Lips are pale
Throat ko” as verbalized by the  Halitosis
patient
Neck “Di naman makati” as  No discomfort when
verbalized by the head is extended
patient  No jugular distension
Respiratory “Di naman ako  Tachypnic breathe
nahihirapan huminga” as pattern (R.R.:24
verbalized by the cpm)
patient  (-) Crackle sound
 during auscultation

Cardiovascular “Di naninikip ang dibdib  Jugular vein is not

ko” as verbalized by the distended
patient  BP: 120/80 mmHg
Abdomen “Nakadumi naman ako ng  Abdomen has no
maayos” as verbalized lesion
by the patient  No visible blood
vessel ( caput
medusae)
Urinary “Di naman ako  Yellowish urine color
nahihirapan umihi” as  No presence of
verbalized by the hematuria
patient
Muscoloskeletal “Nakakagalaw naman ako  No body weakness
ng maayos” as  Normal range of
verbalized by the motion
patient
Neurologic  Able to recognize
specific object
 Able to speak clearly
 Able to reponse in
question accurately
II. LABORATORY STUDIES

HEMATOLOGY (July 13, 2010)

Procedure Result Normal Indications Nursing

Values Consideration
Hemoglobin 133 140-175 Decreased Maintain
G/dL due to poor adequate air
oxygen ventialtion
supply
Hematocrit 0.4 0.42-0.50 Decreased Maintain
due to poor adequate air
oxygen ventialtion
supply
White Blood 6 0-1/hpf increased Monitor
Cells due to temperature
inflammatory
defenses to
suppress
infection

Segmenters 0.58 0.55-0.65 normal -

Lymphocytes 0.42 0.25-0.35 Increased Monitor
due to the temperature
body’s
increased
immune
system
Platelet 270 150- hemolysis Avoid patient
Count 450x109 L to bleed.
Interpretation: The laboratory shows high percentage of Hct levels, an
increased number of WBC and increase number of segmenters.

URINALYSIS (July 13, 2010)

Procedure Result Normal Indications Nursing

Consideration
Urine Color Yellow Yellow normal -
Transparenc Sl. Hazy clear Due to Monitor I/O
y medication
Sp. Gr. 1.015 1.005-1.30 normal -
Protein Trace Negative normal -
Glucose Negative Negative normal -
RBC 0-1 /hpf 0-1 /hpf normal -
WBC 20-27 /hpf 1-3 /hpf Due to the Monitor I/O
presence of
bacteria
Epithelial Occasional / Few normal -
Cells lpf
Amorhous Few /lpf Few normal -
Urates

Interpretation: There is an infection because of too much number of

WBC. There is also a presence of bacteria and Amorhous Urates, which
must be absent.
 FECALYSIS (July 15, 2010)

Procedure Result Normal Indication Nursing

Values Consideration
Color Brown Yellow Due to the DAT
presence of
bacteria
Consistency Watery Semi- Due to the Increased
formed presence of patient’s fluid
bacteria intake
RBC 0-1 /hpf 0-1 /hpf normal -
Pus Cells 0-2 /hpf Absent Due to the -
presence of
bacteria

Interpretation: Presence of Pus Cells and the amount of RBC shows

abnormal feces.

HEMATOLOGY (July 15, 2010) 07:12 AM

Procedure Result Normal Indications Nursing

Values Consideration
Hemoglobin 169 140-175 normal -
G/dL
Hematocrit 0.50 0.42-0.50 normal -
White Blood 5 0-1/hpf increased Monitor
Cells due to temperature
inflammatory
defenses to
suppress
infection
 Segmenters 0.43 0.55-0.65 Decreased; -
indicate
low glucose
level in
the blood
Lymphocytes 0.57 0.25-0.35 Increased -
due to the
body’s
increased
immune
system
Platelet 125 150- hemolysis Avoid the
Count 450x109 L patient to
bleed

Interpretation: There is an increase value of Lymphocytes. Hematocrit

level is above normal.
 HEMATOLOGY (July 15, 2010) 06:38 PM

Procedure Result Normal Indications Nursing

Values Consideration
Hemoglobin 167 140-175 normal -
G/dL
Hematocrit 0.4 0.42-0.50 Decreased Maintain
due to poor adequate air
oxygen ventilation
supply
White Blood - 0-1/hpf - -
Cells
Segmenters - 0.55-0.65 - -
Lymphocytes - 0.25-0.35 - -
Platelet 112 150-450x109 hemolysis
Count L

Interpretation: Platelet count is below normal range.

 HEMATOLOGY (July 15, 2010)

Procedure Result Normal Indications Nursing

Values Consideration
Hemoglobin 163 140-175 normal -
G/dL
Hematocrit 0.49 0.42-0.50 normal -
White Blood - 0-1/hpf - -
Cells
Segmenters - 0.55-0.65 - -
Lymphocytes - 0.25-0.35 - -
Platelet 86 150-450x109 hemolysis Avoid the
Count L patient to
bleed

Interpretation: The result shows that the patient has

thrombocytopenia.

HEMATOLOGY (July 16, 2010)

Procedure Result Normal Indications Nursing

Values Consideration
Hemoglobin 160 140-175 normal -
G/dL
Hematocrit 0.48 0.42-0.50 normal -
White Blood - 0-1/hpf - -
Cells
Segmenters - 0.55-0.65 - -
Lymphocytes - 0.25-0.35 - -
Platelet 76 150-450x109 hemolysis Avoid the
Count L patient to
bleed
Interpretation: The result shows that the patient has
thrombocytopenia.

HEMATOLOGY (July 17, 2010)

Procedure Result Normal Indications Nursing

Values Consideration
Hemoglobin 160 140-175 Normal -
G/dL
Hematocrit 0.48 0.42-0.50 Normal -
White Blood - 0-1/hpf - -
Cells
Segmenters - 0.55-0.65 - -
Lymphocytes - 0.25-0.35 - -
Platelet 95 150-450x109 hemolysis Consult the
Count L physician if
bleeding
occur

Interpretation: The result shows that the patient has

thrombocytopenia.
 SEROLOGY

Typhidot Ig G: Positive
Typhidot Ig M: negative

Cross-Matching

Patient Blood Type: “AB” Rh positive

Date: June 24, 2010
Blood Component: Fresh Frozen Plasma (FFP)
FFB AB1 Unit: 2
Expiry Date: June 24, 2011
Donor: Volunteer
III. FUNCTIONAL ASSESSMENT

1. Health Perception/ Health Management Pattern

The patient recalled that he has a healthy body, except

when he had been in accident. And he only visits the doctor
when he gets sick.

2. Nutritional Metabolic Pattern

The patient has loss his appetite and hasn’t eaten a lot. His
fluid intake also decrease.He is on a DAT (Diet as
Tolerated)

3. Elimination Pattern

Oftentimes, the urinary and fecal elimination is altered due to

the decreased fluid intake.

4. Activity/ Exercise Pattern

The patient is able to do his ADL independently like bathing,

grooming and toileting but the patient is lazy that’s why he
doesn’t perform it. He doesn’t do exercises and always lying in
bed.

5. Sleep Rest Pattern

The patient sometimes experience sleep pattern disturbances

due to itchyness of his skin. There are times that the patient
feels drowsy.

6. Cognitive/ Perceptual Pattern

 The patient was able to understand the responsibilities that
others told him. Through his stay in the hospital, he became
aware about his condition.

7. Self Perception/ Self Concept Pattern

He doesn’t feel pity and hopelessfor himself. He feels the

worth given by his family. There is no disturbed body image.

8. Role-Relationship Pattern

He had more time to bond with his family especially to his

mother. His mother cares a lot to him. He learned to
appreciate the beauty of having a family that gives you
strength and support no matter what.

9. Sexuality-Reproductive Pattern

According to him, he doesn’t think of the things like having a

girlfriend and getting married yet. He is still young for such
matters.

10. Coping-Stress Tolerance Pattern

He shares his problems to his mother. He verbalizes his

feeling.

11. Value-Belief Pattern

He is a Roman Catholic devotee. He was taught by his family to

believe and have fear to GOD.
IV. PROBLEM LIST

A. Actual

Problem No. Problem Date Identified Date Resolved

B. Potential or High Risk

Problem No. Problem Date Identified Date Resolved

1 Risk for July 13, 2010 July 20,2010
Infection
 V. NURSING CARE PLAN

SUBJECTI OBJECTIV ASSESSME PLANNIN INTERVENTI EVALUATIO

VE E NT G ON N

“ Tinatamad - Self care After 1 -Monitor the After 1 hour

akong Unpleasant deficit hour of V/S goal met, the
maligo” as odor related to nursing patient
verbalized lack of interventio -Provide health performed
by the -Dry Skin motivation in n, the teaching on the good hygiene
patient performing patient will client and he
-Presence good perform regarding the cooperated
of hygiene good proper way of in the
Dandruff hygiene effective oral procedure of
and he will hygine. bathing and
V/S taken cooperate proper
as follow: in the -Explain the grooming
procedure procedure of
BP: /80
120
of bathing proper bathing
PR: 72 and proper and hair
RR: 24 grooming brushing on the
T: 36 patient.

-Guide and
support the
patient and let
him perform
the procedure.

-Encourage him
to take a bath
everyday.
VI: ANATOMY AND PHYSIOLOGY

BLOOD

Blood is a specialized bodily fluid that delivers necessary

substances to the body's cells (such as nutrients and oxygen) and
transports waste products away from those same cells.
In vertebrates, it is composed of blood cells suspended in
a liquid called blood plasma. Plasma, which constitutes 55% of blood
fluid, is mostly water (90% by volume), and contains dissolved
proteins, glucose, mineral ions, hormones, carbon dioxide (plasma being
the main medium for excretory product transportation),platelets and
blood cells themselves. The blood cells present in blood are mainly red
blood cells (also called RBCs or erythrocytes) and white blood cells,
including leukocytes and platelets. The most abundant cells in
vertebrate blood are red blood cells. These contain hemoglobin,
an iron-containing protein, which facilitates transportation
of oxygen by reversibly binding to this respiratory gas and greatly
increasing its solubility in blood. In contrast, carbon dioxide is almost
entirely transported extracellularly dissolved in plasma
as bicarbonate ion.
Vertebrate blood is bright red when its hemoglobin is
oxygenated.
Platelets are important in the clotting of blood.
Blood is circulated around the body through blood vessels by the
pumping action of the heart. In animals with lungs, arterial blood
carries oxygen from inhaled air to the tissues of the body,
andvenous blood carries carbon dioxide, a waste product
of metabolism produced by cells, from the tissues to the lungs to be
exhaled.
Medical terms related to blood often begin
with hemo- or hemato- (also spelled haemo- andhaemato-) from
the Ancient Greek word αἷμα (haima) for "blood". In terms
of anatomy andhistology, blood is considered a specialized form
of connective tissue, given its origin in the bones and the presence of
potential molecular fibers in the form of fibrinogen.
FUNCTIONS

Hemoglobin
green = heme groups
red & blue = protein subunits

Heme

Blood performs many important functions within the body including:

 Supply of oxygen to tissues (bound to hemoglobin, which is
carried in red cells)
 Supply of nutrients such as glucose, amino acids, and fatty
acids (dissolved in the blood or bound to plasma proteins (e.g., blood
lipids)
 Removal of waste such as carbon dioxide, urea, and lactic acid
 Immunological functions, including circulation of white blood cells,
and detection of foreign material by antibodies
 Coagulation, which is one part of the body's self-repair
mechanism (the act of blood clotting when one gets cut to stop the
bleeding.)
 Messenger functions, including the transport of hormones and
the signaling of tissue damage
 Regulation of body pH
 Regulation of core body temperature
 Hydraulic functions

CONSTITUENTS OF HUMAN BLOOD

 Blood accounts for 8% of the human body weight,  with an
average density of approximately 1060 kg/m3, very close to pure
water's density of 1000 kg/m3. The average adult has a blood
volume of roughly 5 liters (1.3 gal), composed of plasma and
several kinds of cells (occasionally called corpuscles); these
formed elements of the blood are erythrocytes (red blood cells),
leukocytes (white blood cells), and thrombocytes (platelets). By
volume, the red blood cells constitute about 45% of whole blood,
the plasma about 54.3%, and white cells about 0.7%.
 Whole blood (plasma and cells) exhibits non-Newtonian
fluid dynamics; its flow properties are adapted to flow
effectively through tiny capillary blood vessels with less
 resistance than plasma by itself. In addition, if all human
hemoglobin were free in the plasma rather than being contained
in RBCs, the circulatory fluid would be too viscous for the
cardiovascular system to function effectively.
One microliter of blood contains:

 4.7 to 6.1 million (male), 4.2 to 5.4 million

(female) erythrocytes: In most mammals, mature red blood cells lack
a nucleus and organelles. They contain the blood's hemoglobin and
distribute oxygen. The red blood cells (together
with endothelial vessel cells and other cells) are also marked
byglycoproteins that define the different blood types. The
proportion of blood occupied by red blood cells is referred to as
the hematocrit, and is normally about 45%. The combined surface
area of all red blood cells of the human body would be roughly 2,000
times as great as the body's exterior surface.
 4,000–11,000 leukocytes: White blood cells are part of
the immune system; they destroy and remove old or aberrant cells
and cellular debris, as well as attack infectious agents (pathogens)
and foreign substances. The cancer of leukocytes is called leukemia.
 200,000–500,000 thrombocytes: thrombocytes, also
called platelets, are responsible for blood clotting (coagulation).
They change fibrinogen into fibrin. This fibrin creates a mesh onto
which red blood cells collect and clot, which then stops more blood
from leaving the body and also helps to prevent bacteria from
entering the body.

PLASMA
About 55% of whole blood is blood plasma, a fluid that is the blood's
liquid medium, which by itself is straw-yellow in color. The blood plasma
volume totals of 2.7–3.0 liters (2.8–3.2 quarts) in an average human. It
is essentially an aqueous solution containing 92% water, 8% blood
plasma proteins, and trace amounts of other materials. Plasma
circulates dissolved nutrients, such as glucose, amino acids, and fatty
acids (dissolved in the blood or bound to plasma proteins), and removes
waste products, such as carbon dioxide, urea, andlactic acid.
Other important components include:

 Serum albumin
 Blood-clotting factors (to facilitate coagulation)
 Immunoglobulins (antibodies)
 lipoprotein particles
 Various other proteins
 Various electrolytes (mainly sodium and chloride)
The term serum refers to plasma from which the clotting proteins have
been removed. Most of the proteins remaining are albumin
andimmunoglobulins.
Narrow range of pH values
Blood pH is regulated to stay within the narrow range of 7.35 to 7.45,
making it slightly alkaline. Blood that has a pH below 7.35 is tooacidic,
whereas blood pH above 7.45 is too alkaline. Blood pH, partial
pressure of oxygen (pO2), partial pressure of carbon dioxide (pCO2),
and HCO3 are carefully regulated by a number of homeostatic
mechanisms, which exert their influence principally through
the respiratory system and the urinary system in order to control
the acid-base balance and respiration. An arterial blood gas will
measure these. Plasma also circulates hormones transmitting their
messages to various tissues. The list of normal reference ranges for
various blood electrolytes is extensive.
Bones are especially affected by blood pH as they tend to be used as a
mineral source for pH buffering. Consuming a high ratio of animal
protein to vegetable protein is implicated in bone loss in women.
PHYSIOLOGY

Cardiovascular system

The circulation of blood through the human heart

Blood is circulated around the body through blood vessels by the

pumping action of the heart. In humans, blood is pumped from the
strong left ventricle of the heart through arteries to
peripheraltissues and returns to the right atrium of the heart
through veins. It then enters the right ventricleand is pumped through
the pulmonary artery to the lungs and returns to the left atrium
through thepulmonary veins. Blood then enters the left ventricle to be
circulated again. Arterial blood carries oxygen from inhaled air to all of
the cells of the body, and venous blood carries carbon dioxide, a waste
product of metabolism by cells, to the lungs to be exhaled. However,
one exception includes pulmonary arteries, which contain the most
deoxygenated blood in the body, while the pulmonary veins contain
oxygenated blood.
Additional return flow may be generated by the movement of skeletal
muscles, which can compress veins and push blood through the valves in
veins toward the right atrium.
The blood circulation was famously described by William Harvey in
1628.
Production and degradation of blood cells
In vertebrates, the various cells of blood are made in the bone
marrow in a process called hematopoiesis, which
includes erythropoiesis, the production of red blood cells; and
myelopoiesis, the production of white blood cells and platelets. During
childhood, almost every human bone produces red blood cells; as adults,
red blood cell production is limited to the larger bones: the bodies of
the vertebrae, the breastbone (sternum), the ribcage, the pelvic
bones, and the bones of the upper arms and legs. In addition, during
childhood, the thymus gland, found in the mediastinum, is an important
source of lymphocytes. The proteinaceous component of blood
(including clotting proteins) is produced predominantly by the liver,
while hormones are produced by the endocrine glands and the watery
fraction is regulated by the hypothalamusand maintained by the kidney.
Healthy erythrocytes have a plasma life of about 120 days before they
are degraded by the spleen, and the Kupffer cells in the liver. The liver
also clears some proteins, lipids, and amino acids. The kidney actively
secretes waste products into the urine.
Oxygen transport
Basic hemoglobin saturation curve. It is moved to the right in higher
acidity (more dissolved carbon dioxide) and to the left in lower acidity
(less dissolved carbon dioxide)

About 98.5% of the oxygen in a sample of arterial blood in a healthy

human breathing air at sea-level pressure is chemically combined with
the Hgb. About 1.5% is physically dissolved in the other blood liquids
and not connected to Hgb. The hemoglobin molecule is the primary
transporter of oxygen in mammals and many other species (for
exceptions, see below). Hemoglobin has an oxygen binding capacity of
between 1.36 and 1.37 ml O2 per gram Hemoglobin, which increases the
total blood oxygen capacity seventyfold, compared to if oxygen solely
was carried by its solubility of 0.03 mL O2 per liter blood per
mmHg partial pressure of oxygen (approximately 100 mmHg in
arteries).
With the exception of pulmonary and umbilical arteries and their
corresponding veins, arteriescarry oxygenated blood away from
the heart and deliver it to the body via arterioles and capillaries,
where the oxygen is consumed; afterwards, venules, and veins carry
deoxygenated blood back to the heart.
Under normal conditions in humans at rest, hemoglobin in blood leaving
the lungs is about 98–99% saturated with oxygen. In a healthy adult at
rest, deoxygenated blood returning to the lungs is still approximately
75% saturated. Increased oxygen consumption during sustained
exercise reduces the oxygen saturation of venous blood, which can
reach less than 15% in a trained athlete; although breathing rate and
blood flow increase to compensate, oxygen saturation in arterial blood
can drop to 95% or less under these conditions. Oxygen saturation this
low is considered dangerous in an individual at rest (for instance, during
surgery under anesthesia. Sustained hypoxia (oxygenation of less than
90%), is dangerous to health, and severe hypoxia (saturations of less
than 30%) may be rapidly fatal.
A fetus, receiving oxygen via the placenta, is exposed to much lower
oxygen pressures (about 21% of the level found in an adult's lungs),
and, so, fetuses produce another form of hemoglobin with a much
higher affinity for oxygen (hemoglobin F) in order to function under
these conditions.
Carbon dioxide transport
When blood flows through capillaries, carbon dioxide diffuses from the
tissues into the blood. Some carbon dioxide is dissolved in the blood. A
part of CO2 reacts with hemoglobin and other proteins to
form carbamino compounds. The remaining carbon dioxide is converted
tobicarbonate and hydrogen ions through the action of RBC carbonic
anhydrase. Most carbon dioxide is transported through the blood in
the form of bicarbonate ions.
Carbon dioxide (CO2), the main cellular waste product is carried in
blood mainly dissolved in plasma, in equilibrium
with bicarbonate (HCO3-) and carbonic acid (H2CO3). 86–90% of CO2 in
the body is converted into carbonic acid, which can quickly turn into
bicarbonate, the chemical equilibrium being important in the
pH buffering of plasma. Blood pH is kept in a narrow range (pH between
7.35 and 7.45).
Transport of hydrogen ions
Some oxyhemoglobin loses oxygen and becomes deoxyhemoglobin.
Deoxyhemoglobin binds most of the hydrogen ions as it has a much
greater affinity for more hydrogen than does oxyhemoglobin.
Lymphatic system
In mammals, blood is in equilibrium with lymph, which is continuously
formed in tissues from blood by capillary ultrafiltration. Lymph is
collected by a system of small lymphatic vessels and directed to
the thoracic duct, which drains into the left subclavian vein where
lymph rejoins the systemic blood circulation.
Thermoregulation
Blood circulation transports heat throughout the body, and
adjustments to this flow are an important part of thermoregulation.
Increasing blood flow to the surface (e.g., during warm weather or
strenuous exercise) causes warmer skin, resulting in faster heat loss.
In contrast, when the external temperature is low, blood flow to the
extremities and surface of the skin is reduced and to prevent heat loss
and is circulated to the important organs of the body, preferentially.
Hydraulic functions
The restriction of blood flow can also be used in specialized tissues to
cause engorgement, resulting in an erection of that tissue; examples
are the erectile tissue in the penis and clitoris.
Another example of a hydraulic function is the jumping spider, in which
blood forced into the legs under pressure causes them to straighten
for a powerful jump, without the need for bulky muscular legs.

PREVENTING BLOOD LOSS

When a blood vessel is damaged, blood can leak into other tissues and
interfere with the normal tissue function or blood can be lost from the
body. Small amounts of blood from the body can be tolerated but new
blood must be produced to replace the loss blood. If large amounts of
blood are lost, death can occur.
BLOOD CLOTTING
Platelet plugs alone are not sufficient to close large tears or cults in
blood vessels. When a blood vessel is severely damaged, blood clotting
or coagulation results in the formation of a clot. A clot is a network of
threadlike protein fibers called fibrin, which traps blood cells,
platelets and fluids. The formation of a blood clot depends on a number
of proteins found within plasma called clotting factors. Normally the
clotting factors are inactive and do not cause clotting. Following injury
however, the clotting factors are activated to produce a clot. This is a
complex process involving chemical reactions, but it can be summarized
in 3 main stages; the chemical reactions can be stated in two ways: just
as with platelets, the contact of inactive clotting factors with exposed
connective tissue can result in their activation. Chemicals released
from injured tissues can also cause activation of clotting factors.
After the initial clotting factors are activated, they in turn activate
other clotting factors. A series of reactions results in which each
clotting factor activates the next clotting factor in the series until the
clotting factor prothrombin activator is formed. Prothrombin activator
acts on an inactive clotting factor called prothrombin. Prothrombin is
converted to its active form called thrombin. Thrombin converts the
inactive clotting factor fibrinogen into its active form, fibrin. The
fibrin threads form a network which traps blood cells and platelets and
forms the clots.
CONTROL OF CLOT FORMATION
Without control, clotting would spread from the point of its initiation
throughout the entire circulatory system. To prevent unwanted
clotting, the blood contains several anticoagulants which prevent
clotting factors from forming clots. Normally there are enough
anticoagulants in the blood to prevent clot formation. At the injury
site, however, the stimulation for activating clotting factors is very
strong. So many clotting factors are activated that the anticoagulants
no longer can prevent a clot from forming.

CLOT RETRACTION AND DISSOLUTION

After a clot has formed, it begins to condense into a denser compact
structure by a process known as clot retraction. Serum, which is plasma
without its clotting factors, is squeezed out of the clot during clot
retraction. Consolidation of the clot pulls the edges of the damaged
vessels together, helping the stop of the flow of blood, reducing the
probability of infection and enhancing healing. The damaged vessel is
repaired by the movement of fibroblasts into damaged area and the
formation of the new connective tissue. In addition, epithelial cells
around the wound divide and fill in the torn area. The clot is dissolved
by a process called fibrinolysis. An inactive plasma protein called
plasminogen is converted to its active form, which is called plasmin.
Thrombin and other clotting factors activated during clot formation, or
tissue plasminogen activator released from surrounding tissues,
stimulate the conversion of plasminogen to plasmin. Over a period of a
few days the plasmin slowly breaks down the fibrin.
VII: PATHOPHYSIOLOGY
DENGUE FEVER SYNDROME

Dengue fever (pronounced UK: /ˈdɛŋɡeɪ/, US: /ˈdɛŋɡiː/) and dengue

hemorrhagic fever (DHF) are acute febrile diseases which occur in
the tropics, can be life-threatening, and are caused by four closely
related virus serotypes of the genus Flavivirus, family Flaviviridae.It is
also known as breakbone fever, since it can be extremely painful.
Each serotype is sufficiently different that there is no cross-
protection and epidemics caused by multiple serotypes
(hyperendemicity) can occur. Dengue is transmitted to humans by
the Aedes (Stegomyia) aegyptior more rarely the Aedes
albopictus mosquito, both of which feed exclusively during daylight
hours. 

CAUSE
DENV
Dengue fever is caused by Dengue virus (DENV), a mosquito-borne
flavivirus. DENV is an ssRNA positive-strand virus of the
familyFlaviviridae; genus Flavivirus. There are four serotypes of DENV.
The virus has a genome of about 11000 bases that codes for three
structural proteins, C, prM, E; seven nonstructural proteins, NS1,
NS2a, NS2b, NS3, NS4a, NS4b, NS5; and short non-coding regions on
both the 5' and 3' ends.
 DENV E and M Proteins and the Assembly and Maturation of the
Viral Glycoprotein Shell
E protein
The DENV E (envelope) protein, found on the viral surface, is important
in the initial attachment of the viral particle to the host cell. Several
molecules which interact with the viral E protein (ICAM3-grabbing non-
integrin.,,CD209 , Rab 5 , GRP 78 , and The Mannose Receptor)have
been shown to be important factors mediating attachment and viral
entry.
prM/M protein
The DENV prM (membrane) protein, which is important in the
formation and maturation of the viral particle, consists of seven
antiparallel β-strands stabilized by three disulphide bonds.
The glycoprotein shell of the mature DENV virion is comprised of 180
copies each of the E protein and M protein. The immature virion starts
out with the E and prM proteins forming 90 heretodimers that give a
spiky exterior to the viral particle. This immature viral particle buds
into the endoplasmic reticulum and eventually travels via the secretory
pathway to the golgi apparatus. As the virion passes through the TGN
it is exposed to low pH. This acidic environment causes a
conformational change in the E protein which disassociates it from the
prM protein and causes it to form E homodimers. These homodimers lay
flat against the viral surface giving the maturing virion a smooth
appearance. During this maturation pr peptide is cleaved from the M
peptide by the host protease, furin. The M protein then acts as a
transmembrane protein under the E-protein shell of the mature virion.
The pr peptide stays associated with the E protein until the viral
particle is released into the extracellular environment. This pr peptide
acts like a cap, covering the hydrophobic fusion loop of the E protein
until the viral particle has exited the cell.
Non-Structural proteins
NS3 protein
The DENV NS3 is a serine protease, as well as an RNA helicase and
RTPase/NTPase. The protease domain consists of six β-strands
arranged into two β-barrels formed by residues 1-180 of the protein.
The catalytic triad (His-51, Asp-75 and Ser-135), is found between
these two β-barrels, and its activity is dependant on the presence of
the NS2B cofactor. This cofactor wraps around the NS3 protease
domain and becomes part of the active site. The remaining NS3
residues (180-618), form the three subdomains of the DENV helicase.
A six-stranded parallel β-sheet surrounded by four α-helices make up
subdomains I and II, and subdomain III is composed of 4 α-helices
surrounded by three shorter α-helices and two antiparallel β-strands.
NS5 protein
The DENV NS5 protein is a 900 residue peptide with a
methyltransferase domain at its N-terminal end (residues 1-296) and a
RNA-dependent RNA polymerase at its C-terminal end (residues 320–
900). The methyltransferase domain is comprised of an α/β/β sandwich
flanked by N-and C-terminal subdomains. The DENV RNA-dependent
RNA polymerase is similar to other to other RdRps containing palm,
finger, and thumb subdomains and a GDD motif for incorporating
nucleotides.
The potential factors causing hemorrhagic fever are varied. The most
suspected factors are human's cross-serotypic immune response and
membrane fusion process.
Human antibodies produced in response to the virus actually increase
the infection
DENGUE PREVENTION
There is no vaccine to prevent dengue. Prevention centers on avoiding
mosquito bites when traveling to areas where dengue occurs.
Eliminating mosquito breeding sites in these areas is another key
prevention measure.
Avoid mosquito bites when traveling in tropical areas: Use mosquito
repellents on skin and clothing. When outdoors during times that
mosquitoes are biting, wear long-sleeved shirts and long pants tucked
into socks. Avoid heavily populated residential areas. When indoors,
stay in air-conditioned or screened areas. Use bednets if sleeping
areas are not screened or air-conditioned. If you have symptoms of
dengue, report your travel history to your doctor. Eliminate mosquito
breeding sites in areas where dengue might occur: Eliminate mosquito
breeding sites around homes. Discard items that can collect rain or
run-off water, especially old tires. Regularly change the water in
outdoor bird baths and pet and animal water containers.

SIGNS, SYMPTOMS, COMPLICATION WITH RATIONALE

Signs and Symptoms

The disease manifests as fever of sudden onset associated with

headache, muscle and joint pains (myalgias and arthralgias—severe pain
that gives it the nickname break-bone fever or bonecrusher disease),
distinctive retro-orbital pain, and rash. The classic dengue rash is a
generalised maculopapular rash with islands of sparing. A hemorrhagic
rash of characteristically bright red pinpoint spots, known
aspetechiae can occur later during the illness and is associated
with thrombocytopenia. It usually appears first on the lower limbs and
the chest; in some patients, it spreads to cover most of the body.
There may also be severe retro-orbital pain, (a pain from behind the
eyes that is distinctive to Dengue infections), and gastritis with some
combination of associated abdominal pain, nausea, vomiting coffee-
grounds-like congealed blood, or diarrhea. Some cases develop much
milder symptoms which can be misdiagnosed as influenza or other viral
infection when no rash or retro-orbital pain is present. Febrile
travelers from tropical areas may transmit dengue inadvertently to
previously Dengue free populations of Aedes (Stegomyia)
Aegypti mosquitoes, having not been properly diagnosed for Dengue.
Patients only transmit Dengue when they are febrile and bitten
by Aedes (Stegomyia) Aegypti mosquitoes, or (much more unusually) via
blood products. The classic dengue fever lasts about two to seven days,
with a smaller peak of fever at the trailing end of the disease (the so-
called "biphasic pattern"). Clinically, theplatelet count will drop until
after the patient's temperature is normal. Cases of DHF also show
higher fever, variable hemorrhagic phenomena including bleeding from
the eyes, into the gut, and oozing blood from skin
pores, thrombocytopenia, and hemoconcentration. When Dengue
infections proceed to DHF symptoms, DHF causes vascular leak
syndrome which includes fluid in the blood vessels leaking through the
skin and into spaces around the lungs and belly. This fluid loss and
severe bleeding can cause blood pressure to fall, then Dengue Shock
Syndrome (DSS) sets in, which has a high mortality rate.

COMPLICATION
CLASSIFICATION:
1.Severe, frank type
>flushing, sudden high fever, severe hemorrhage, followed by sudden
drop of
temperature, shock and terminating in recovery or death
2. Moderate
>with high fever but less hemorrhage, no shock present
3. Mild
 >with slight fever, with or without petichial hemorrhage but
epidemiologically related to typical cases usually discovered in the
course of invest or typical cases
GRADING THE SEVERITY OF DENGUE FEVER
Grade 1:
>fever
>non-specific constitutional symptoms such as anorexia, vomiting and
abdominal pain
>absence of spontaneous bleeding
>positive tourniquet test
Grade 2:
>signs and symptoms of Grade 1: plus
>presence of spontaneous bleeding: mucocutaneous, gastrointestinal
Grade 3:
>signs and symptoms of Grade 2 with more severe bleeding: plus
>evidence of circulatory failure: cold, clammy skin, irritability, weak to
compressible pulses, narrowing of pulse pressure to 20 mmhg or less,
cold
extremities, mental confusion
Grade 4:
>signs and symptoms of Grade 3, declared shock, massive bleeding,
pulse less
and arterial blood Pressure = 1 mmhg (Dengue Syndrome/DS)

SUSCEPTABILITY, RESISTANCE, AND OCCURRENCE: >all persons

are susceptible
>both sexes are equally affected
>age groups predominantly affected are the pre-school age and school
age
>adults and infants are not exempted
>peak age affected: 5-9 years old
The diagnosis of dengue is usually made clinically. The classic picture is
high fever with no localising source of infection, a rash
withthrombocytopenia and relative leukopenia - low platelet and white
blood cell count. Dengue infection can affect many organs and thus may
present unusually as liver dysfunction, renal impairment, meningo-
encephalitis or gastroenteritis.

1. Fever, headaches, eye pain, severe dizziness and loss of appetite.

2. Hemorrhagic tendency (positive tourniquet test, spontaneous
bruising, bleeding from mucosa, gingiva, injection sites, etc.;
vomiting blood, or bloody diarrhea)
3. Thrombocytopenia (<100,000 platelets per mm³ or estimated as
less than 3 platelets per high power field)
4. Evidence of plasma leakage (hematocrit more than 20% higher
than expected, or drop in hematocrit of 20% or more from
baseline following IV fluid, pleural effusion, ascites,
hypoproteinemia)
5. Encephalitic occurrences.
Dengue shock syndrome is defined as dengue hemorrhagic fever plus:

 Weak rapid pulse,

 Narrow pulse pressure (less than 20 mm Hg)
 Cold, clammy skin and restlessness.
Dependable, immediate diagnosis of dengue can be performed in rural
areas by the use of Rapid Diagnostic Test kits, which also
differentiate between primary and secondary dengue
infections.Serology and polymerase chain reaction (PCR) studies are
available to confirm the diagnosis of dengue if clinically indicated.
Dengue can be a life threatening fever.

TREATMENT
The mainstay of treatment is timely supportive therapy to
tackle circulatory shock due to hemoconcentration and bleeding.
Close monitoring of vital signs in the critical period (up to 2 days
after defervescence - the departure or subsiding of a fever) is
critical. Increased oral fluid intakeis recommended to
prevent dehydration. Supplementation with intravenous
fluids may be necessary to prevent dehydration and significant
concentration of the blood if the patient is unable to maintain oral
intake. A platelet transfusion may be indicated if the platelet level
drops significantly (below 20,000) or if there is significant
bleeding. The presence of melena may indicate internal
gastrointestinal bleeding requiring platelet and/or red blood cell
transfusion.
Aspirin and non-steroidal anti-inflammatory drugs should be
avoided as these drugs may worsen the bleeding tendency
associated with some of these infections. Patients may
receive paracetamol preparations to deal with these symptoms if
dengue is suspected

VIII: MEDICAL-SURGICAL MANAGEMENT

1. PHARMACOTHERAPEUTICS

Brand Mechanism Indication Adverse Nursing

Name/ of Action and Reaction Consideration
Generic Dosage
Name

Ibuprofen May inhibit -Mild to Hematologic: *May decrease

prosta moderate -leukopenia neutrophil, WBC,
glandin pain -neutropenia RBC, platelets and
synthesis -thrombo granulocyte count.
to produce *Blurred or
-Fever cytopenia
anti- diminished vision
inflamma and changes in
tory, *400 mg CNS: color vision may
analgesic *i tab -dizziness occur
and anti- *Serious GI
*PO -headache
pyretics toxicity, including
effect. *q6o
peptic ulcer and
GI: bleeding can occur
-peptic in the patient.
ulceration *If patient
-occult blood consumes 3 or
loss more alcoholic
drinks per day
-nausea
drug may cause
Skin: stomach bleeding.
-hyper *Tell patient to
sensitivity take with meals or
milk to reduce
adverse GI
reactions
*Warn patient to
avoid hazardous
activities that
require mental
alertness until
effects in CNS
are known
 Brand Mechanism Indication Adverse Nursing
Name/ of Action and Reaction Consideration
Generic Dosage
Name

Parace Thought to -Mild pain Hematologic: *Use cautiously in

 tamol produce -leukopenia patient with
(Aceta analgesia -Fever -neutropenia hepatic
by blocking dysfunction
Minophen) -hypo
pain *May decrease
impulses by *500 glycemia
glucose, Hgb
inhibiting mg/tab
levels and Hct
synthesis *PO Metabolic: *May decrease
of
*PRN -Jaundice neutrophils, WBC,
prostaglan
RBC, and platelets
din in the
counts
CNS
*Warn patient
that high doses
can cause liver
damage

Brand Mechanism Indication Adverse Nursing

Name/ of Action and Reaction Consideration
Generic Dosage
Name
Aeknil -Reduces -headache Renal and *Should be given
(Parace fever by hepatic with care to
acting on damage can patient and
tamol) -Fever
the hypo result impaired hepatic
thalamus and renal function
to cause -Pain
vaso
dilation -Tonsillitis
and
sweating
*500
mg/tab
*PO
*PRN

Brand Mechanism of Indication and Adverse Nursing

Name/ Action Dosage Reaction Consideratio
Generic n
Name

Cef -Inhibits Treatment of Renal and *Should be

triaxone bacterial cell suscep hepatic given with
wall synthesis tible damage can care to
by binding to infections result patient and
one or more of including impaired
the penicillin chancroid, hepatic and
binding gastro renal
proteins function
enteritis, lyme
(PBP’s) which
disease,
is turn inhibits
meningitis,
the final
syphilis and
transpeptidati
thypoid fever
on step of
peptigo
glycan *i amp
synthesis in *IV
bacterial cell
*PRN
walls, thus
inhibiting cell’s
wall bio
synthesis

IX: Progress Note:

Day 1Mr. Japs confined at room 308 of San Jose Trauma and
Hospital. Take his vital signs at eight o'clock in the morning (T=
37.7; BP= 100/80; RR= 25cpm; PR= 76bpm). Excrete blood at
 10AM for blood typing procedure. Patient's still having a fever,
poor appetite, and with evidence of flushed skin. Around 7:30PM
doctors advice the blood transfusion; then conducted a
Hematology examination, the result shows that patient is having a
Thrombocytopenia and still closely monitor the platelet counts.

Day 2 Mr. Japs vital signs is normal (T= 35.7; BP= 100/80;
RR= 25cpm; PR= 76bpm). Dr. Alberto ordered to repeat HHP
(Hemoglobin, Hematocrit, Platelets) four hours after the blood
transfusion. Around 06:47 PM doctor's order to repeat the HHP
tonight by 7:00 PM. Mr. Japs, Still have a Thrombocytopenia
after the results of Laboratory examinations.

X. DISCHARGE HEALTH TEACHING

XI: SUMMARY OF CLIENT’S STATUS OR CONDITION AS OF
LAST CONTACT
 Republic of the Philippines

EULOGIO “AMANG” RODRIGUEZ

INSTITUTE OF SCIENCE AND TECHNOLOGY

Cavite Campus
General Mariano Alvarez, Cavite

College of Arts and Sciences

Magallanes, Marialyn V.
 Manansala, Vanessa A.

Nejar, Ma. Luz Teresa L.

Obaña, Florence Bernadette M.

Palomares, Krishna A.

Secapore, Kevin V.

Villanueva, Ramon K.

Ms. Anna Mae L. Dublado R.N.