LICEO DE CAGAYAN UNIVERSITY

COLLEGE OF NURSING
NCM501202

NCM501202
A Case Study

Submitted to:

Mr. Rex Mulat RN.

AS PARTIAL FULFILLMENT OF THE COURSE REQUIREMENT

FOR NCM501202

Submitted by:

Leamei L. Pondoyo
 TABLE OF CONTENTS
I. Introduction
a. overview
b. objective of the study
c. Significance of the Study
d. scope and limitation of the study
II. Health History
a. profile of the patient
b. family and personal health history
c. history of present illness
d. chief compliant
III. Developmental Data
IV. Medical Management
a. Medical orders and rationale
b. Laboratory results
c. Drug study
V. Pathophysiology with anatomy and physiology
VI. Nursing assessment (System Review and Nursing assessment II)
VII. Nursing Management
a. Ideal Nursing Management (NCP)
b. Actual Nursing Management (SOAPIE)
VIII. Health Teachings
IX. Prognosis
XI. Evaluation and Implications
XII. Bibliography
 I. INTRODUCTION

A. Overview

Dengue fever is a disease caused by a family of viruses that are

transmitted by mosquitoes. It is an acute illness of sudden onset that usually
follows a benign course with headache, fever, exhaustion, severe joint and
muscle pain, body weakness, and rash. The presence (the "dengue triad") of
fever, rash, and headache (and other pains) is particularly characteristic of
dengue. The virus is contracted from the bite of a striped Aedes aegypti mosquito
that has previously bitten an infected person. Dengue fever is a benign acute
febrile syndrome occurring in tropical regions. The mosquito flourishes during
rainy seasons but can breed in water-filled flower pots, plastic bags, and cans
year-round. One mosquito bite can inflict the disease. The virus is not contagious
and cannot be spread directly from person to person. There must be a person-to-
mosquito-to-another-person pathway.

After being bitten by a mosquito carrying the virus, the incubation period
ranges from three to 15 (usually five to eight) days before the signs and
symptoms of dengue appear. Dengue starts with chills, headache, pain upon
moving the eyes, and low backache. Painful aching in the legs and joints occurs
during the first hours of illness. The temperature rises quickly as high as 104° F
(40° C), with relative low heart rate (bradycardia) and low blood pressure
(hypotension). Fever and other signs of dengue last for two to four days, followed
by rapid drop in temperature (defervescence) with profuse sweating. This
precedes a period with normal temperature and a sense of well-being that lasts
about a day.

The transmission of the virus to mosquitoes must be interrupted to prevent

the illness. To this end, patients are kept under mosquito netting until the second
bout of fever is over and they are no longer contagious. The prevention of
dengue requires control or eradication of the mosquitoes carrying the virus that
causes dengue, empty stagnant water from old tires, trash cans, and flower pots.

The Philippines Department of Health (DOH) today reported that a total of

2,332 dengue cases have been admitted to sentinel hospitals nationwide this
year. Partial reports from the DOH National Epidemiology Center (NEC) indicate
a 58% decrease in the number of cases this year compared with the same period
last year. The NEC report also revealed that the regions with the highest number
of cases were the National Capital region (732 cases), Region 3 (307), Region 5
(268), and Region 7 (231). The ages of cases ranged from 1 month to 75 years
old, with forty-six percent (535) of the cases belonging to the 1-9 years age
group.

B. Objective of the study

A case study is designed to identify health problems or potential

health threats that would arise in a specific client. As student nurses, it is
expected from us that we will apply what we learn from our lesson in the
actual setting such as this case.

At the end of our 2 days duty, we will be able to:

 Gather information about the patient’s history and lifestyle that may
have predisposed her health condition, gathering subjective and
objective data and perform physical assessment.
 Identify actual and potential problems associated with the patient’s
health condition.

 Understand and be aware of patient’s disease condition and its

corresponding pathophysiology.
  Provide 24 hours care to the patient and bestow quality-nursing care,
utilizing the knowledge based on the nursing process and critical
thinking skills.

 Impart health teachings to the patient in order to prevent potential

problems associated with her condition.

C. Significance of the Study

The study will provide constructive benefits to the client as well as his
significant others. This will provide them with more information on how to
promote a healthy lifestyle and will broaden their understanding on the disease
condition and most of all will gain quality nursing care and this study will also
benefit and help the nursing students conducting this particular study which
would help them develop and improve more their skills and broaden their
knowledge about this particular case in which it would be helpful and useful
experience for their upcoming care toward this case and most importantly it will
broaden our understanding on the disease process.

D. Scope and Limitation of the study

D1. Scope of the study includes:

a. Data collected through assessments, interviews with the patient

and family members, and clinical records.
b. Actual problems and its associated interventions that would be
applied throughout the patient’s stay in the hospital.

c. Developing a plan of care that will reduce identified problems and

complications coordinating and delegating interventions within the
plan.
 d. Further evaluating the effectiveness of nursing interventions that
have been applied to the patient’s entire course of therapy.

D2. Limitation of the study includes:

• This study is only limited to 2 days of actual care from August12 to

August13, 2009. Time of care is limited from 6 o’ clock in the morning
until 2 in the afternoon.

• The information gathered is only limited from information given

and obtained from the patient’s chart and patient’s itself.
 II. HEALTH HISTORY

A. Patient’s Profile

Name: Mr. T.J.G.

Birth date: December 21, 2000

Address: Zone 5, Bugo, CDO

Age: 8 years old

Sex: Male

Religion: Roman Catholic

Civil Status: Child

Income: 5000/month

Nationality: Filipino

Occupation: N/A

Informant: Mr. T.J.G.

Temp: 37.8 Degree Celsius

Pulse Rate: 88 cpm

Respiratory Rate: 31 bpm

BP: 100/70 mmHg

Height: 56cm
Weight: 34lbs.

Date of Admission: August 18, 2009

Time: 10:55 am

B. Family and Personal Health History

During our assessment, we were able to interview the client together with
his father. He mentioned that he did experienced fever, colds and headache for
the past 3 days. Regarding about his bowel movement and diet he used to
defecate once a day and used to eat anything that is prepared for the day. His
father stated that they have a family history of asthma disease and the patient
manifest the signs of asthma. He stated that he has a non productive cough, and
he suffers chest pain when he is coughing. Other than the latter, no other
hereditary disease from both of his parents are within the patient’s condition.
Patient did take a medicine such as paracetamol, biogesic when he
experienced such fever, cough and colds for the past few days and until now he
takes paracetamol for his fever. He stated that he had no food and drug allergies.

C. Chief Complaints and History of Present Illness

The case of Mr. T.J.G., 8 years old, male, with a religious affiliation of
Roman Catholic, a son of Mr. and Mrs. Guillena. He was a natural born Filipino
and was admitted in Maria Reyna Hospital last August 18, 2009 at exactly 10: 55
am.
Our patient mentioned that for the past 3 days he did experienced repeat
of fever, colds and headache. So, he admitted to the said hospital with a chief
complaint of fever. And he was diagnosed of having a dengue fever symptom.
He was accommodated on the said hospital.

III. DEVELOPMENTAL DATA

Erikson's Theory of Psychosocial Development

School- Age Child (6-12 years old)

Industry versus Inferiority (Competence)

Erikson viewed the developmental task of the school- age period as

developing industry versus inferiority, or accomplishment rather than inferiority.
During the preschool period children learned initiative- how to do something.
When they are encouraged in their efforts to do practical tasks or make practical
things and are praised and rewarded for the finished results, their sense of
industry grows. Parents who don’t show appreciation for their children’s efforts
may cause them to develop a sense of inferiority rather than pride and
accomplishment. The child’s grows to include the school and community
environment and success or failure in those settings can have a lasting impact.
Here the child learns to master the more formal skills of life: (1) relating with
peers according to rules (2) progressing from free play to play that may be
elaborately structured by rules and may demand formal teamwork, such as
baseball and (3) mastering social studies, reading, arithmetic. Homework is a
necessity, and the need for self-discipline increases yearly. The child who,
because of his successive and successful resolutions of earlier psychosocial
crisis, is trusting, autonomous, and full of initiative will learn easily enough to be
industrious. However, the mistrusting child will doubt the future. The shame - and
guilt-filled child will experience defeat and inferiority.

Freud’s Psychoanalytic Theory

Freud saw the school- age period as “latent phase”, a time in which
children’s libido appears to be diverted into concrete thinking. . During the latency
period, children pour this repressed libidal energy into asexual pursuits such as
school, athletics, and same-sex friendships. But soon puberty strikes and the
genitals once again become a central focus of libidal energy.

Developmental Task Theory

Robert Havighurst

In this age our patient belongs which is under the School –Age Child also
achieves some of the characteristics under the School –Age Child. Like, she
uses the primary language of their culture to communicate their needs and
feelings, and separate from their caregivers for extended periods. She shows
increasing interest in group activities and in making things. She works at many
activities that involve motor, cognitive and social skills.

Developmental Tasks of Middle Adulthood

1, feed and dress themselves
2. same sex of peers acceptance
3. Participate in school activities
4. involves in sports
5. define objects by use
6. solves practical problems
7. follows rules to be a good person in own eyes and eyes others
 That developmental task of school- age stated above was achieved by my
patient.

IV. MEDICAL MANAGEMENT

A. Doctors Order

DATE & ORDER RATIONALE

TIME
August 18, Please admit under the To provide care and close
2009
service of Dr. Agnes monitoring
10:55 am Secure consent to care and To provide care and close
management monitoring
Vital signs every 2hours To check if there is changes or
any abnormalities
Labs
 CBC EXAM.  CBC test, which is a
complete blood count that
measure the amount of white
and red blood cells and
 U/A EXAM. platelets in your blood.
 For routine laboratory test
upon admission and to
assess presence of infection
 FECALYSIS EXAM. in the urine.
  To determine any
abnormalities regarding about
stool and if there’s presence
of blood
Start D5 LR 1 liter @ To maintain hydration
30gtts/min
Meds
 Paracetamol 250mg/ml = Relieves pain and reduces
fever.
7,5ml q4
 Famotidine 20mg IV every
12 hours = Decreases gastric acid levels
and prevents heartburn.
I & O every shift to monitor water retention
BP q 2 hours to observe unusualities
DAT , avoid dark colored to detect if there’s a presence
foods of bleeding
Refer accordingly For further evaluation
D5 0.3 NaCl 30 gtts/min for hydration to client
3:00pm

11pm

August 19, D5 0.3 NaCl @ 30 gtts/min For hydration of the client

2009
Repeat CBC CBC test, which is a complete
blood count that measure the
amount of white and red blood
cells and platelets in your
blood.
PCM 250mg q 4 hours, PRN To lower down the temperature
for Fever
within normal range
Continue meds For treatment regimen
 C. LABORATORY RESULTS

COMPLETE BLOOD COUNT August 18, 2009

Determination Results Interpretation
Total White Blood Cells 7.8 x 10 Increased; this may
indicate infection,
inflammation and
trauma.
Hemoglobin 13.3 g/dL normal
Hematocrit 40.0 % Decreased; this may
indicate anemia
Platelet Count 321,000 normal
Differential Count:
Segmenters 86 % Abnormal since the
normal average percent
is 50-65%
Lymphocytes 26 % normal.

URINALYSIS August 18, 2009

Characteristics Results Interpretation
Color Yellow Normal
Clarity clear Normal
pH 6.0 Normal
Specific Gravity 1.025 Normal
Glucose Negative (-) Normal
Albumin (-) Normal
 RBC 0-2 Normal since the normal
range is 0-3
Epithelium Few Normal

FECALYSIS August 18, 2009

Result Interpretation
Color Brown Bacterial infection
Consistency Soft
Bacteria Positive
RBC 0-2 /hpf
Pus cells 0-2/hpf
Parasite/Ova No ova or parasites seen

Clinical Chemistry August 19, 2009

Determination Results Interpretation

Creatinine 1.2 mg/dl Normal

IV. Anatomy and physiology
Antigens are large molecules (usually proteins) on the surface of cells, viruses,
fungi, bacteria, and some non-living substances such as toxins, chemicals,
drugs, and foreign particles. The immune system recognizes antigens and
produces antibodies that destroy substances containing antigens.

Antigens were originally defined as non-self molecules which bound specifically

to antibodies. In practice, the term antigen is used to mean any molecule
recognized by the immune system.

Antigens which induce adaptive immunity are called immunogens. All

immunogens are antigens, and are usually called antigens unless their ability to
induce an immune response is being discussed. Some antigens, called haptens,
are not immunogenic unless they are covalently linked to immunogenic carriers
usually proteins. Haptens can bind antibodies once the antibodies are produced,
but haptens will not induce antibody synthesis on their own. Small non-protein
organic molecules, for example the antibiotic penicillin, are haptens.
Active immunity is induced by exposure to antigen. Antigen dose and the route
and timing of antigen contact, as well as immunogenicity, influence the
magnitude and nature of the immune response. Very high or very low doses of
antigen induce tolerance, the inability to respond to that antigen, while
intermediate doses induce immunity. We are generally tolerant to cell-bound and
soluble antigens present in our own bodies. Oral tolerance to foods is common,
although some foods induce allergic reactions.

Antigens encountered in body tissues through subcutaneous or intramuscular

injection are carried by lymph and macrophages into the lymph nodes, where
they usually elicit formation of serum IgG antibody. Antigens encountered by
mucosal routes are taken up by M cells and induce secretory IgA production. IgE
is often made to worm parasites and to protein allergens such as pollen that are
encountered at low doses across mucus membranes. Introducing antigens into
the blood stream requires larger doses for inducing immunity, as the majority of
antigen is quickly removed and destroyed in the spleen and liver.

Red blood cells [RBC's] make the blood look red and it's the RBC's that deliver
oxygen to the cells in the body and carry back waste gases in exchange. The
RBC's look like tiny little inner tubes or donuts under a microscope. In the middle
is where the oxygen sits.
White blood cells [WBC's] are part of your body's defense against disease.
Some WBC's will attack and kill germs by devouring them and others will attack
and kill by manufacturing and waging chemical warfare agents against disease.
Platelets are other cells that help your body repair itself after injury. Platelets
play an important role in blood coagulation, hemostasis and blood thrombus
formation. When a small vessel is injured, platelets adhere to each other and the
edges of the injury and form a plug that covers the area. The plug or blood clot
formed soon retracts and stops the loss of blood.
 V. PATHOPHYSIOLOGY

Definition: Dengue Fever is a mild viral illness transmitted by mosquitoes. It is

characterized by fever, rash, and muscle and joint pains.

Precipitating Factors:
Predisposing Factors: 1 contaminated blood
1. age (toddler-school age) 2. environment
2. season/weather 3. lifestyle

Bites of Virus carrying Aedes aegypti

Mosquieto injects fluid into victim’s skin

Virus enters bloodstream

Infect cells and generate cellular response

 Innitiate immune response
(Stimulates release of cytokines)

Cytokines destroy cell membrane and cell wall

(Viral antigens found in monocytes)
Fluid shift

When treated early with doctor prescribed

Medications and manage to prevent the appearance
of other symptoms

IVF’s and Electrolytes replacement

and precautions

Patient’s recovery
Name: : Mr. T.J.G. Date: August 18. 2009
Pulse: 88 BP: 100/70 mmHg Temp:37.8 Height: 56cm Weight: 34kls.

August 18, 2009 (1st day assessment)

An [X] is placed in the area of abnormality. Comment at the space provided. Indicate the location
of the problem in the figure using [X].
EENT:
[ ] impaired vision [ ] blind
[ ] pain redden [ ] drainage
[ ] gums [ ] hard of hearing [ ] deaf Tachypnea RR= 31cpm
[ ] burning [ ] edema [ ] lesion teeth
[ ] assess eyes ears nose Chest pain
[ ] throat for abnormality [X] no problem
RESP: Non-
[ ] asymmetric [X ] tachypnea [ ] barrel chest productive
[ ] apnea [ ] rales [ ] cough cough
[ ] bradypnea [ ] shallow [ ] rhonchi
[ ] sputum [ ] diminished [ ] dyspnea
[ ] orthopnea [ ] labored [ ] wheezing Dry skin
[ ] pain [ ] cyanotic and warm
[ ] assess resp. rate, rhythm, pulse blood to touch
[ ] breath sounds, comfort [ ] no problem
CARDIOVASCULAR:
[ ] arrhythmia [ ] tachycardia [ ]numbness
[ ] diminished pulses [ ] edema [ ] fatigue
[ ] irregular [ ] bradycardia [ ] murmur
[ ] tingling [ ] absent pulses [ ] pain
Assess heart sounds, rate rhythm, pulse, blood
Pressure, circ., fluid retention, comfort
[ X ] no problem
GASTROINTESTINAL TRACT:
[ ] obese [ ] distention [ ] mass headache
[ ] dyspagea [ ] rigidity [ ] pain
[ ] assess abdomen, bowel habits, swallowing
[ ] bowel sounds, comfort [ ] no problem
GENITO – URINARY AND GYNE
[ ] pain [ ] urine [ ] color [ ] vaginal bleeding
[ ] hematuria [ ] discharge [ ] noctoria
[ ] assess urine frequency, control, color, odor, comfort
[ ] gyne bleeding [ ] discharge [ X ] no problem Fever with
NEURO: Temp: 37.8C
[ ] paralysis [ ] stuporus [ ] unsteady [ ] seizure
[ ] lethargic [ ] comatose [ ] vertigo [ ] tremors
[ ] confused [ ] vision [ ] grip D5 LR
[ ] assess motor, function, sensation, LOC, strength 30gtts/min
[ ] grip, gait, coordination, speech [ X ] no problem
MUSCULOSKELETAL and SKIN:
[ ] appliance [ ] stiffness [ ] itching [ ] petechie
[ ] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [ ] poor turgor [ ] cool [ ] flushed
[ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic moist
[ ] assess mobility, motion gait, alignment, joint function
[ ] skin color, texture, turgor, integrity [ X] no problem
Name: : Mr. T.J.G.
Date: August 19. 2009
Pulse: 85 BP: 100/70 mmHg Temp:37.3 Height: 56cm Weight: 34kls.

August 19, 2009 (2nd day assessment)

An [X] is placed in the area of abnormality. Comment at the space provided. Indicate the location
of the problem in the figure using [X].
EENT:
[ ] impaired vision [ ] blind
[ ] pain redden [ ] drainage
[ ] gums [ ] hard of hearing [ ] deaf Tachypnea RR= 31cpm
[ ] burning [ ] edema [ ] lesion teeth
[ ] assess eyes ears nose Chest pain
[ ] throat for abnormality [X] no problem
RESP: Non-
[ ] asymmetric [X ] tachypnea [ ] barrel chest productive
[ ] apnea [ ] rales [ ] cough cough
[ ] bradypnea [ ] shallow [ ] rhonchi
[ ] sputum [ ] diminished [ ] dyspnea
[ ] orthopnea [ ] labored [ ] wheezing Dry skin
[ ] pain [ ] cyanotic and warm
[ ] assess resp. rate, rhythm, pulse blood to touch
[ ] breath sounds, comfort [ ] no problem
CARDIOVASCULAR:
[ ] arrhythmia [ ] tachycardia [ ]numbness
[ ] diminished pulses [ ] edema [ ] fatigue
[ ] irregular [ ] bradycardia [ ] murmur
[ ] tingling [ ] absent pulses [ ] pain
Assess heart sounds, rate rhythm, pulse, blood
Pressure, circ., fluid retention, comfort
[ X ] no problem
GASTROINTESTINAL TRACT:
[ ] obese [ ] distention [ ] mass Headache
[ ] dyspagea [ ] rigidity [ ] pain
[ ] assess abdomen, bowel habits, swallowing
[ ] bowel sounds, comfort [ ] no problem
GENITO – URINARY AND GYNE
[ ] pain [ ] urine [ ] color [ ] vaginal bleeding
[ ] hematuria [ ] discharge [ ] noctoria
[ ] assess urine frequency, control, color, odor, comfort
[ ] gyne bleeding [ ] discharge [ X ] no problem
NEURO:
[ ] paralysis [ ] stuporus [ ] unsteady [ ] seizure
[ ] lethargic [ ] comatose [ ] vertigo [ ] tremors
[ ] confused [ ] vision [ ] grip D5.3NaCl
[ ] assess motor, function, sensation, LOC, strength 30gtts/min
[ ] grip, gait, coordination, speech [ X ] no problem
MUSCULOSKELETAL and SKIN:
[ ] appliance [ ] stiffness [ ] itching [ ] petechie
[ ] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [ ] poor turgor [ ] cool [ ] flushed
[ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic moist
[ ] assess mobility, motion gait, alignment, joint function
[ ] skin color, texture, turgor, integrity [ X] no problem
NURSING ASSESSMENT II
SUBJECTIVE OBJECTIVE
COMMUNICATION:
[ ] hearing loss “ok raman akong [ ] glasses [ ] languages
[ ] visual changes pandungog” as verbalized [ ] contact lenses [ ] hearing aide
[ x] denied by the patient. Pupil size: 2-3mm [ ] speech difficulties
Reaction: Pupil Equally Round Reactive to Light
and Accommodation
_________________________________________
OXYGENATION: Resp. [] regular [ x ] irregular
[ ] dyspnea “ ubunon ko usahay” as Describe: has above normal respiratory rate
[ ] smoking history verbalized by the patient.
No Smoking history R: Right lung symmetrical to left lung.
[ x] cough L: Left lung symmetrical to right lung.
[ ] sputum
[ ] denied
CIRCULATION: Heart Rhythm [ x ] regular [ ] irregular
[ x ] chest pain “ mgsakit akong dughan Ankle Edema: no ankle edema noted.
[ ] leg pain kong ubuhon ko” as
[ ] numbness of verbalized by the patient Pulse Car Rad. DP Fem*
extremities R _+_____+______+ ___ _ N/O____N/O______
[ ] denied L __+_____+______+___ _ N/O____N/O______
Comment/s: pulses are palpable
_________________________________________
_________________________________________
NUTRITION:
Diet: Diet as Tolerated “ ok raman sad akong [ ]dentures [ x ]none
[ ]N[ ]V panlasa sa pagkaon” as
Character verbalized by the patient. Full Partial with patient
[ ] recent change in
weight appetite Upper [ ] [ ] [ ]
[ ] Difficulty swallowing Lower [ ] [ ] [ ]
[ ] denied
ELIMINATION: Bowel sounds:
Usual bowel pattern [ ] urinary frequency Normo active____
_________________ 6 times a day Abdominal Distention
[ ] constipation [ ] urgency Present [ ] yes [ ] no
Remedy [ ] dysuria Urine* (color,
__________ _ [ ] hematuria consistency, odor)
Date of last BM [ ] incontinence ___ _
___August 19, 2009___ [ ] polyuria
[ ] diarrhea [ ] foley in place * if foley are in place?
character [ x] denied
_________________

MGT. OF HEALTH & ILLNESS: Briefly describe the patient’s ability to follow
[ ] alcohol [ x] denied treatments (diet, meds, etc.) for chronic health
(amount & frequency) problems (if present).
none
[ ] SBE Last Pap Smear: _______N/A____________ Patient is faithful in following his medical regimen
LMP:____N/A______________ and his family are very supportive.

SUBJECTIVE OBJECTIVE
SKIN INTEGRITY:
[ ] DRY “ ok raman akong [ ] dry [ ] cold [ ] pale
panit,wala may gakatul2x” [ ] flushed [x] warm temp.: 37.8 oC
[ ] other as verbalized by the [ ] moist [ ] cyanotic
[ ] denied patient, *rashes, ulcers, decubitus (describe size, location,
drainage: no rashes, ulcers found upon assessment.

ACTIVITY/ SAFETY:
[ ] convulsion “ usahay malipong ko kung [ ] LOC and orientation: conscious and coherent,
[x ] dizziness motindog,labad pud akong oriented to time, place and person around him.
[ ] limited motion of ulo.” As verbalized by the Gait: [ ] walker [ ] cane [ ] other
Joints patient.
Limitation in [ ] steady [ ] unsteady gait, walks slowly with
Ability to assitance
[ ] ambulate [ ] sensory and motor losses in face or
[ ] bathe self extremities: no sensory and motor losses in face and
[ ] other extremities
[ ] denied [ ] ROM limitations: no problem
COMFORT/SLEEP/AWA
KE: “ Ok raman akong pag [ ] facial grimaces
[ ] pain (location) tulog” as verbalized by [ ] guarding
Frequency the patient. [ ] other signs of pain: _________
Remedies [ ] side rail release form signed (60 + years)
[ ] nocturia _____N/A__________________________
[ ] sleep difficulties
[ ] denied

COPING: Observed non-verbal behavior: patient is so

Occupation: ___Student________
Members of household: _6_______
Most supportive person: Father
approachable and accommodating to his nurses,
student nurses and doctor.
The person and his phone number that can be
reached anytime: _____none____
_________________________________________

SPECIAL PATIENT INFORMATION

_____34lbs._______ Daily weight _______N/A_____ PT/OT _____________
_110/70 _ BP q shift ______N/A______ Irradiation
______N/A_ ____ Neuro vs color-yellow and clear_ Urine test __
______N/A_ ____ CVP/SG Reading _______ ______N/A___ __ 24 hour Urine Collection

Date
Diagnostic/ I.V.
order Date done Date Disc.
Laboratory Exams Fluids/Blood
ed

Augus CBC August 18, 2009 D5 LR @ 30 gtts/min August 18,2009

t 18,
2009

Augus August 18, 2009 D5.3 NaCl August 18,2009

t 18, URINALYSIS
2009
Augu
st 19, Clinical August 19, 2009
2009
Chemistry
Augu Fecalysis August 19, 2009
st
18.2
009

VII. NURSING MANAGEMENT

A. IDEAL NURSING CARE PLAN
NURSING DIAGNOSIS: Hyperthermia
Risk factors may include
Increased metabolic rate, illness
Dehydration
Direct effect of circulating endotoxines on the hypothalamus; altering
temperature regulation
Possibly evidenced by
Increased in body temperature higher than the normal range
Flushed skin, warm to touch
Increased respiratory rate, tachycardia
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Thermoregulation (NOC)
Demonstrate temperature within normal range, be free of chills.
Experience no associated complications.

ACTIONS/INTERVENTIONS
Fever Treatment (NIC)
Independent
Monitor client temperature (degree
and pattern) note shaking,
chills/profuse diaphoresis
Monitor environmental temperature,
limit/ aid bed linens as indicated.
Provide rapid tepid sponge baths,
avoid use of alchohol.
RATIONALE
Temperature of 102 degree F- 106
degree F suggest acute infectious
diseases process.
Room temperature/ number of
blankets should be altered to maintain
nera normal body temperature.
May help reduce fever. Alchohols is
very drying to skin.

ACTIONS/INTERVENTIONS
Infection Control (NIC)
Collaborative
Administer antipyretics,
acetamenophen
Provide cooling balnket as indicated.
RATIONALE
Used to reduce fever by its central
action on the hyphothalamu; fever
should be controlled in the clients who
are neutropic or asplenic. However,
fever may be benificial in limiting
growth of organisms and enhancing
autodestruction of infected cells.
Used to reduce fever, usually higher
than normal,when brain damage or
seizure can occur.

NURSING DIAGNOSIS: acute headache pain

May be related to
Increased cerebral vascular pressure
Possibly evidenced by
Reports of throbing pain located in sub occipital region, present on
awakening and dissapearing spontaneously after being up and about
Reluctance to move head, rubbing head, avoidance of bright lights and
noise, wrinkled brow, clenched fists
Report of stiffness of neck, dizziness, blurred vision, nausea and vomiting
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Pain control (NOC)
Report pain/ discomfort isd relieved/ controlled.
Verbalized methods that provide relief.
Follow prescribed pharmacologic regimen.

RATIONALEACTIONS/INTERVENTI
ONS RATIONALE

Establishs baseline, in order to Facilitates diagnosis of problem and

detremine needed interventions to
asses progress of recovery
Attemping to maintaibn usual sleep
routines promotes rest and maximize
energy and endurance.
Enhances sense of well being and
expectation to return to usual
activities.
Helps identify/ monitor degree of
fatigue and potential for complication.
Oxygen may be neede to improve
tolerance to activity, treat underlying
cause for fatigue. Blow by oxygen can
provide some benefit if child refuses to
wear mask.
Pain Mangement (NIC)
Independent
Determine specific of pain; location,
intensity(0-10 scale.
Encourage maintain bedrest during
acute phase
intuition of apprpriate therapy. Helpful
in evaluating effectiveness of therapy.
Minimize stimulation/promote
relaxation.
Measures that reduce cerebral
vascular pressure and that slow/block
sympathetic response are effective in
relieving haedache and associated
complications.
Dizziness and blurred vision
frequently are associated with
vascular headache.Client may also
experience episoeds of postural
hypotension, causing weakness when
ambulation.
Reduce/ control pain and decrease
stimulation of the sympathetic nervous
system.
Refuse/control pain and decrease
stimulation of the sympathetic nervous
system.

Provide/recommend
nonpharmacologic measures for relief
of headache;e.g, cool clothe to
forehead and diversional activities.
Assist client with ambulation as
neede.

Pain Mangement (NIC)

Independent

Provide liquid . soft foods, frequently

mouth care if nosebleeds occur or
nasal packing has been done to stop
bleeding.
Collaborative
Administer medication as indicated;
analgesics

B. ACTUAL NURSING INTERVENTION

S “Gi.tugnaw ko, init ako pamati sa akong lawas”
 Temp.: 37.8˚C
 Warm to touch
O
 Covering his whole body with blanket
A Hyperthermia secondary to dengue fever as evidence by
increased body temperature 37.8 ˚C

P At the end of 30 minutes client’s temperature will be lowered

down into normal range
Independent
 Performed tepid sponge bath
I
= to lower down the temperature within normal range
  Monitored vital signs especially the temperature
= to determine if there’s any increase or decreased in
patient’s temperature or abnormalities of the v/s
 Encouraged intake of oral fluids 2-3 liters/day
= to prevent dehydration
 Encouraged the patient not to cover his whole body
with blanket
= because this may trigger the increased of his
temperature and may cause prolonged fever
Dependent:
 Administered paracetamol 250 mg P.O as ordered
= to lower down the temperature
E At the end of 30 minutes client’s temperature was lowered
down into normal range 37.4˚C

“labad akong ulo”as verbalized by the patient.

S
 Temp.: 37.8˚C
 Reports of headache
O
 Always lying on bed
A Acute headache pain r/t fever

P At the end of 15 minutes the client will be able to report

relieve of pain.
Independent

I  Provided quiet environment and calm activities

*to avoid anxiety and prevent fatigue Monitored vital
signs especially the temperature

 Instructed with relaxation technique (Deep breathing

exercise)
 * to relax patient and provide comfort
 Encourage maintain bed rset
* promote relaxation.
Dependent:
 Administered analgesic 250 mg P.O as ordered
* to help in reducing pain
E At the end of 15 minutes the client was able to report relieve
of pain.

S “malipong ko kong mutindog ko” as verbalized by the

patient.
 Temp.: 37.8˚C
 Reports of headache
O
 Always lying on bed
A Activity intolerance r/t pain and weakness

P At the end of 15 minutes the client will be able to report

absence of fatigue.
Independent
 Determine usual sleep/ rest routine and bedtime
I rituals. Plan care with adequate rest periods.
* Attemping to maintaibn usual sleep routines
promotes rest and maximize energy and endurance.
 Promote participation in individually appropriate
recreational and diversional activites.
* Enhances sense of well being and expectation to
return to usual activities
 Monitor response to activity including BP,
pulse,respiratory rate,skin,and behavior
* Helps identify/ monitor degree of fatigue and potential
for complication..
Dependent:
  Administered paracetamol 250 mg P.O as ordered
* to help in reducing pain and fever.
E At the end of 15 minutes the client was able to report
Patient is
absence of fatigue.
advised to take
all the
medications like
paracetamol
prescribed by
the physicians
as to the
prescribed
dosage,
prescribed
route,
prescribed time
and as on how
many days will it
be consumed
and its
importance of
complying with
medication
schedule. This
will help the
patient for fast
treatment or
recovery.
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.
 Early ambulation if patient can tolerate and
advised to the patient as soon as the patient is
Exercise discharge from the hospital institution. This would
help the patient for a fast recovery.

Encourage to practice universal precaution this

may prevent the patient’s health from bacteria
that may cause infection and thus may cause any
other complications. Management of such
condition would be through hydration and doing
Treatment 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.
 Rest and fluid intake for adequate hydration is
important
Any odd signs such as fever or recurrence of
fever must be immediately reported to the
Out- Patient physician. This would help for continues
( Check-up) management on the patients condition and further
evaluation if the patient is doing well.
Encourage to maintain prescribed diet DAT with
no chocolates and dark colored foods as
prescribed. Eat foods that give energy and
vitamins, over all a great source for fighting
fevers. Instruct to eat foods that are low fat, low
Diet
fiber, non-irritating and non-carbonated

IX. Prognosis
Criteria Poor Good
a. Onset of Illness √
b. Duration of Illness √
c. Attitude & Willingness to take medication √
d. Precipitating factor √
e. Family Support √

a) Onset of Illness - The onset of illness is poor, since the client had an acute
onset of illness. This will mean increase for possible infections and
complications because of the body’s lessened ability to combat pathogens.
b) Duration of Illness - The duration of illness is good. Since the patient is sick
and his immune system was compromised, it contributed to the factors that
made his recovery slow. But after 2 days of hospitalization, the patient’s
condition has progresses because his fever was gone.
c) Attitude & Willingness to take medication - Attitude and willingness to take
medication is good because the patient was willing to take the medication as
prescribed.
d) Precipitating Factors - The precipitating factor is good since the members of
the family of the patient were aware of the disease condition of the patient.
e) Family Support - With regards to the patient’s support system, there was a
positive response despite of the financial problem of the family. The family
supported the patient, most especially his parents.

Overall the prognosis is good since the family was able to support him and
even himself was willing to cooperate and to participate regarding the care that
was given to him hence the participation of the family and from the patient in the
nursing and medical management will made a significant contribution in attaining
recovery.

X. Evaluation and Implication

After two (2) days of clinical duty, the objectives of the study were
obtained and limitations were also observed. Thorough assessment was done to
assess for any problems that were identified and appropriate nursing
interventions were planned to intervene for these problems. Patient was able to
gained information on how to avoid infection by maintaining a clean environment,
improving a healthy lifestyle and able to promote a proper hygiene and patient
was also instructed on how to maintain a good proper nutrition and adequate rest
periods and gladly the patient shows improvement to those interventions. A
number of nursing care plans were designed and were properly implemented and
showed good outcomes. 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.All of the nursing care plans were designed for short term goals which are
very effective. Generally, the cares provided were effective and it helped the
client in developing a temporary cure for the problems that were identified.
We were able to gain more understanding about the disease condition and
enhance more their knowledge about the disease process. And they were also
given a chance to implement some of their nursing intervention and it helps them
a lot because they were able to established a good relationship with the patient
and significant others and improve more my nursing skill on how to deal with this
kind of patient and able to realize that those experience that I’ve got on the area
is really essential to my profession. Through this experience the students will be
able to be more competent to work in the area and on how to take care of this
kind of client and most of all we were able to gained more confidence to our
selves and this would push the students to work harder and learned more.

XI. Referrals and Follow-Up

Our patient was given education and we encouraged him and his family to follow
a regimen to avoid possible complications of his medical condition.
 Instruct and receive return demonstration of ability to take and record pain
experience to rate 10 as the highest.
 Explain and discuss patient’s role in control of risk factors and
precipitating or aggravating factors (e.g., maintaining clean environment)
 Review signs/symptoms that require immediate medical attention, e.g.,
severe pain.
 Identify community resources/support groups and visiting home health
nurse as indicated.
  Raise the level of awareness of patient on health problems that she may
encounter.

.
  Our patient was also instructed about his medical condition and the ways
to prevent further complications. If medications are prescribed for the prevention
of infection, the actions and importance of the medication are explained to the
patient. 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.

XII. Bibliography

 Clayman, C.B (1989) Home Medical Encyclopedia. 1st Edition. Rindom

House, Inc. United States.

 Gilliam, Stephen.Springhouse Nurse’s Guide.Lippincott Williams &

Wilkins.2006

 Kozier, B.,E. Gleonora, K. Blais, J.M. Wilkinson (2001) Fundamentals of

Nursing. 5th Edition. JB Lippincott Company. Philadelphia.page 759
&1227

 Lippincott Wiliams and Wilkins. Nursing Drug Handbook. A Wolters

Kluwer business.27th edition

 Kozier, erb, Blas,Wilkinson. 1998. Fundamentals of Nursing. Addison

Wesley.
  Nettina, Sandara. 2001. The Lippinocotts Manual of Nursing Practice. 17th
edition. Lippincott William and Wilkins.

 Maternal and Child Health Nursing. Fifth Edition. Adele Pillitteri

 Nursing Care Plans Edition 7. Marilynn E. Doenges. Mary Frances

Moorhouse. Alice C. Murr

 www.nursingcrib.com

 www.medicinenet.com

VII. Health Teachings

Medication

NURSING DIAGNOSIS: Activity intolerance

May be related to
Generalized weakness, bedrest or immobility
Imbalance between oxygen supply and demand
Pain, stress
Possibly evidenced by
Report of fatigue or weakness, lack of energy,dyspnea,abnormal heart rate
or blood pressure response to activity, inability to maintain usual routine
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Endurance (NOC)
Participate in costumary activities at desired level
Report absence of fatigue

ACTIONS/INTERVENTIONS
Activity therapy (NIC)
Independent
Ascertain child’s usual level of activity, taking into account age and
developmental level
Determine usual sleep/ rest routine and bedtime rituals/ security objects. Plan
care with adequate rest periods.

Promote participation in individually appropriate recreational and diversional

activites.

Monitor response to activity including BP, pulse,respiratory rate,skin,and

behavior
Collaborative
Provide/ monitor response to oxygen administration via appropriate route and
effects of medications.