Introduction

Dengue fever, also known as break bone fever, is an

acute febrile infectious disease caused by the dengue virus. Typical symptoms
include headache, a characteristic skin rash, and muscle and joint pains; in a
small proportion the disease progresses to life-threatening complications such
as dengue hemorrhagic fever (which may lead to severe hemorrhage)
and dengue shock syndrome (where a very low blood pressure can cause
organ dysfunction).
Dengue is usually transmitted by the mosquito Aedes aegypti, and
rarely Aedes albopictus. The virus exists in four different types, and an infection
with one type usually gives lifelong immunity to that type, but only short-term
immunity to the others. There is currently no available vaccine, but measures to
reduce the habitat and the number of mosquitoes, and limiting exposure to bites,
are used to decrease the incidence of dengue.
Treatment of acute dengue is supportive, using either oral or
intravenous rehydration for mild or moderate disease, and intravenous
fluids and blood transfusions for more severe cases. The rate of infection has
increased dramatically over the last 50 years, with around 50–100 million people
being infected yearly. A global disease, dengue is currently endemic in more than
110 countries. Early descriptions of the condition date from 1779, and its viral
cause and the transmission were elucidated in the early 20th century. Dengue
has become a worldwide problem since the Second World War.

1
Patient’s Profile

Name: A.S.

Room #: Dengue ward

Hospital #: 11-0446

Date admitted: 2-14-11

Address: City of Sta. Rosa Laguna

Gender: Male

Bday: October 29, 1994

Birth Place: Sta. Rosa

Age: 16

Nationality: Filipino

Religion: Roman Catholic

Admitting Physician: Dra. A

Attending Physician: Dra. J

Diagnosis: Dengue Fever

2
Patient’s History

Chief Complaint:

Fever

History Of present Illness:

4 days PTA with abdominal pain, Vomiting and decreased in appetite.

Vital Signs:

T: 37.7 Cº
BP: 110/70 mmHg
PR: bpm
RR: cpm

3
Physical Assessment

Body Part Findings

Interpretation
Head Round in shape; Normal
symmetrical; with frontal,
parietal, temporal and
occipital prominences.

Scalp Smooth; white in color; Normal

no lesions noted; no
tenderness; no dandruff
and lice noted.

Hair Black and curly hair; Normal

evenly distributed.

Face Symmetrical facial Due to possible stress, a

features; with generalized deficiency of vitamins,
pimples on face. diet and certain facial
products.

Eyes Symmetrically black in Normal

color; pupils constricts
when diverted to light
dilates when she gazes
afar; conjunctivas are
pink; eyelashes are
equally distributed and
skin around the eyes is
intact; eyes involuntary
blink.
Ears Symmetrical; no Normal
tenderness; no lesions.

Nose . No swelling of mucus Normal

membrane and presence
of nasal hairs were seen;
uniform in color; nasal
septum are intact; no
tenderness; no lesions.

Mouth and Lips Pale in color; dry and Due to loss of fluid,
cracked lips. possible dehydration.

Tongue Pinkish in color; free of Normal

4
 swelling and lesions;
moves freely.

Teeth and Gums Pink gums; moist and no Normal

swelling.

Skin Dark skin complexion; no Normal

edema; good skin turgor.

Neck Moves freely Normal

Neck muscles Equal in size; head Normal

centered

Lymph nodes No palpable lymph nodes Normal

Thyroid gland No palpable areas of Normal

enlargement of masses
and nodules

Thorax Symmetrical chest Normal

expansion; spine
vertically aligned; no
tenderness; no masses

Abdomen Flat abdominal contour Normal

with symmetrical
movements; no
tenderness; no masses.

Upper extremities:
Hands Small in size with five Normal
fingernails in each side;
nails are short; small
dusty particles present

Arms Able to move through Normal

active ROM

Lower extremities Symmetrical with good Normal

ROM

Neurological Normal
assessment: Patient is silent but
Behavior conscious and coherent
upon interaction.

5
Motor functioning Able to move extremities Normal
through active ROM; able
to push down/up on his
hands.

Sensory Sensory system is intact; Normal

able to distinguish touch,
pain, hot and cold.

6
Review of Anatomy and Physiology

ANATOMY AND PHYSIOLOGY

Components of Blood

Plasma
Plasma is the liquid component of blood, in which the red blood cells, white blood
cells, and platelets are suspended. It constitutes more than half of the blood's
volume and consists mostly of water that contains dissolved salts (electrolytes)
and proteins. The major protein in plasma is albumin. Albumin helps keep fluid
from leaking out of blood vessels and into tissues, and albumin binds to and
carries substances such as hormones and certain drugs. Other proteins in
plasma include antibodies (immunoglobulins), which actively defend the body
against viruses, bacteria, fungi, and cancer cells, and clotting factors, which
control bleeding.

Plasma has other functions. It acts as a reservoir that can either replenish
insufficient water or absorb excess water from tissues. When body tissues need
additional liquid, water from plasma is the first resource to meet that need.
Plasma also prevents blood vessels from collapsing and clogging and helps
maintain blood pressure and circulation throughout the body simply by filling
blood vessels and flowing through them continuously. Plasma circulation also
plays a role in regulating body temperature by carrying heat generated in core
body tissues through areas that lose heat more readily, such as the arms, legs,
and head.

Red Blood Cells

Red blood cells (also called erythrocytes) make up

about 40% of the blood's volume. Red blood cells
contain hemoglobin, a protein that gives blood its red
color and enables it to carry oxygen from the lungs
and deliver it to all body tissues. Oxygen is used by
cells to produce energy that the body needs, leaving
carbon dioxide as a waste product. Red blood cells carry carbon dioxide away
from the tissues and back to the lungs. When the number of red blood cells is too
low (anemia), blood carries less oxygen, and fatigue and weakness develop.

7
When the number of red blood cells is too high (polycythemia), blood can
become too thick, which may cause the blood to clot more easily and increase
the risk of heart attacks and strokes.

White Blood Cells

White blood cells (also called leukocytes) are fewer in number than red blood
cells, with a ratio of about 1 white blood cell to every 600 to 700 red blood cells.
White blood cells are responsible primarily for defending the body against
infection. There are five main types of white blood cells.

Neutrophils

The most numerous type, help protect the body against

infections by killing and ingesting bacteria and fungi and
by ingesting foreign debris

Lymphocytes consist of three main types: T

lymphocytes and natural killer cells, which both help
protect against viral infections and can detect and
destroy some cancer cells, and B lymphocytes, which
develop into cells that produce antibodies.

Monocytes ingest dead or damaged cells and

help defend against many infectious organisms.

8
Eosinophils kill parasites, destroy cancer cells, and are involved in allergic
responses.

Basophils also participate in allergic responses.

Some white blood cells flow smoothly through the

bloodstream, but many adhere to blood vessel walls or
even penetrate the vessel walls to enter other tissues.
When white blood cells reach the site of an infection or
other problem, they release substances that attract more white blood cells. The
white blood cells function like an army, dispersed throughout the body but ready
at a moment's notice to gather and fight off an invading organism. White blood
cells accomplish this by engulfing and digesting organisms and by producing
antibodies that attach to organisms so that they can be more easily destroyed.

When the number of white blood cells is too low (leukopenia), infections are more
likely to occur. A higher than normal number of white blood cells (leukocytosis)
may not directly cause symptoms, but the high number of cells can be an
indication of a disease such as an infection or leukemia.

Platelets

Platelets (also called thrombocytes) are cell-like particles that are smaller than
red or white blood cells. Platelets are fewer in number than red blood cells, with a
ratio of about 1 platelet to every 20 red blood cells. Platelets help in the clotting
process by gathering at a bleeding site and clumping together to form a plug that
helps seal the blood vessel. At the same time, they release substances that help

9
promote further clotting. When the number of platelets is too low
(thrombocytopenia), bruising and abnormal bleeding become more likely. When
the number of platelets is too high (thrombocythemia), blood may clot
excessively, producing a stroke or heart attack.

Formation of blood cells

Red blood cells, most white blood cells, and platelets are produced in the bone
marrow, the soft fatty tissue inside bone cavities. Two types of white blood cells,
T and B lymphocytes, are also produced in the lymph nodes and spleen, and T
lymphocytes are produced and mature in the thymus gland.

Within the bone marrow, all blood cells originate from a single type of
unspecialized cell called a stem cell. When a stem cell divides, it first becomes
an immature red blood cell, white blood cell, or platelet-producing cell. The
immature cell then divides, matures further, and ultimately becomes a mature red
blood cell, white blood cell, or platelet.

The rate of blood cell production is controlled by the body's needs. Normal blood
cells last for a limited time (ranging from a few hours to a few days for white
blood cells, to about 10 days for platelets, to about 120 days for red blood cells)
and must be replaced constantly. Certain conditions may trigger additional
production of blood cells. When the oxygen content of body tissues is low or the
number of red blood cells decreases, the kidneys produce and release
erythropoietin, a hormone that stimulates the bone marrow to produce more red
blood cells. The bone marrow produces and releases more white blood cells in
response to infections. It produces and releases more platelets in response to
bleeding.

The circulatory system consists of 3 components:

1. Blood vessels
2. Heart
3. Blood

10
Blood Vessels
These are hollow, tubular vessels which conduct the blood from the heart to the
tissues and from the tissues to the heart. There are 3 type of blood vessels,
arteries, capillaries and veins.

Arteries
Arteries are vessels which carry blood away from the heart. They are thick walled
vessels. They are elastic in nature, have a narrow lumen, are deep seated in the
body parts and have no valves in them. The blood flowing through the arteries
carry oxygenated blood in them, except the pulmonary artery which carries
deoxygenated blood to the lungs. The average diameter of a an artery is
500 mm.
The arterial wall has three coats namely tunica interna, tunica media and tunica
adventitia. The tunica interna is composed of endothelial cells. The tunica media
is the middle layer and is compound of elastic and simple muscle fibers. The
tunica adventitia is composed of white connective tissue and elastic fibers. The
smallest branches of an artery are called arterioles. The walls of the arteries are
supplied with a set of blood vessels called vaso vasonum.

Capillaries
The arterioles further divide into smaller vessels called meta arterioles which
have a diameter of 70mm which in turn divide into capillaries. They are the
thinnest blood vessels and their walls are formed of a single layer of endothelial
cells. These form a connective link between the arterioles and the veins. They
were discovered by Marcello Malpighi in 1661. The endothelium allows the
exchange of materials like the nutrients, CO2, O2, hormones and waste products
between the blood and the surrounding tissue cells through the tissue fluid.

Veins
The arteriole capillaries join to form venous capillaries which then join to form the
venules and veins. The veins are thin walled vessels. The walls of the veins have
all the three layers as in an artery, but they are comparatively thinner, less elastic
and less muscular. The pressure of the blood in a vein is low and the speed is
slow. It has a wide lumen and is superficial.

11
Action of Semi-lunar Valve in a Vein

Valves are present in most of the veins to prevent the backward flow of blood.
Veins are also supplied with vasa vasorum, the nutrient blood vessels.
Blood
The blood is a fluid connective tissue. It is opaque and somewhat sticky. It is
more viscous than distilled water with a viscosity of 4.7 and slightly alkaline in
nature, Oxygenated blood is bright red while the deoxygenated blood is purple
coloured.
Blood flows in the blood vessels due to the pumping action of the heart. It forms
about 6-10% of the body weight and about 30-35% of the ECF. Adult humans
contain about 5 litres of blood.

12
Pathophysiology
Modifiable Factor
NonmodifIable factor 1. Environmenal Condition
1. Age 2. Mosquito carrying virus
2. Geographic Area 3. Immunocomromise
4. Knowledge deficit

Aedes Aegypti (dengue virus carrier)

Bite from mosquito (portal entry from the skin)

Allowing dengue virus to be inoculated towards the circulation

Virus rapidly disseminated into the blood and stimulates WBC that
produces immunoglobulins,monocytes and neutrohil

Antibodies will attach to the viral antigens and macrophages

will perform phagocytosis within the cells

Dengue virus replicates in the cell

Cellular direct destruction and infection of red bone marrow

precursor cells as well as Immunological shortened platelet

Thrombocytopenia

13
Increase number and size of the pores in the capillaries which
leads to a leakage of fluid from the blood

SIGNS AND SYMPTOMS

1. High Fever 5. Decreased
Platelet

2. Headache 6. Bleeding

3. Petechial Rashes 7. Shock

4. Abdominal Pain

DENGUE

14
Medical Management

Date/Time Doctor’s Order Rationale

February.14,2011 Secure consent Consent is for legal

9pm purposes
BP= 90/60
Temp.= 36.4°C DAT except dark colored Can eat everything he
Wt. = 48.5kgs. foods wants except foods that
bright in color, to provide
good nutrition of the patient
and in order to determine if
there is bleeding

IVF: D5LR 1L @ 36gtts/min D5LR IV was used by

patients in the early stage
of dengue to replace
electrolytes and maintain
hydration status of the
patient.

Meds:
Paracetamol 500mg 1 Paracetamol was used to
tab decrease the fever of the
OMX 1 cap Q12 patient. OMX is used as
Omeprazole 20mg cap nutritional supplement.
OD Omeprazole is use to block
the production of acid in the
stomach.

VS Q4 For proper monitoring of the

patient

February.15,2011 Maintain IVF: D5LR 1L To prevent dehydration of

8am @36gtts/min the patient.

10:30am To follow D5LR 1L @36 For continuous prevention

gtts/min of dehydration

2:20pm VS Q2 For monitoring

15
 OMX 1 cap Q12 OMX is used as nutritional
supplement.

Cetirizine (Virlix) 1 tab OD Is a kind of anti-allergic

drugs.

3:00pm To follow D5LR 1L @

36gtts/min

9:45pm Repeat Hct/platelet count It is used to detect if there

BP= 110/70 now then Q8 is any infections or viruses
(+) nose bleeding (small in the body.
amount)
For CT, BT, blood typing CT is use to examine
certain parts of the body
thoroughly. BT is to transfer
blood to the patient. Blood
typing is done before BT to
determine the exact type of
blood to be given.

9:50pm Carry out Hct, platelet It is done to determine

count, blood typing now infections in the body

Monitor VS Q1. Record For strict monitoring of the

please patient

11:00pm To follow D5LR 1L at To replace electrolytes in

(+) nose bleeding 36gtts/min the body
BP= 100/70
Suggest Vit. K 1 amp IV Q8 Vitamin K is use to for
x3 doses blood coagulation.

11:40pm Shift Omeprazole oral to Shift to IV for rapid effects.

(-) irritation at nostrils 40mg IV OD

February.16,2011 TF: D5LR 1.2Lx8° To replace electrolytes in

12:14am the body

Start Omeprazole IV now Omeprazole is use to block

the production of acid in the

16
 stomach
Diagnostic Examination

Date Request: February 14, 2011

8:00am

Hematology
Exam name Normal Values Result
Hemoglobin 110-140 gm/L 143
Hematocrit 0.37-0.47 0.43
RBC count 4.5-5x10”/l 4.5
WBC count 4.5-10x10”/l 3.7 Low white blood
cell count is a
decrease
in disease-
fighting cells
circulating in
your blood.
Platelet count 150-400x10 146 reduced platelet
count is an
increased risk of
bleeding.

Segmenters 0.50-0.70% 0.68

Lymphocyte 0.20-0.40% 0.39
Eosinophil 0.0-0.04% -
Monocyte 0.0-0.05% -
Basophils 0.0-0.01% -
Stabs 0.0-0.04% -

17
Date Request: February 14, 2011
5:00pm

Hematology
Exam name Normal Values Result
Hemoglobin 110-140 gm/L 147
Hematocrit 0.37-0.47 0.44
RBC count 4.5-5x10”/l 4.9
WBC count 4.5-10x10”/l 4.1 Low white blood
cell count is a
decrease
in disease-
fighting cells
circulating in your
blood.
Platelet count 150-400x10 159

Segmenters 0.50-0.70% 0.58

Lymphocyte 0.20-0.40% 0.41 An increase in
lymphocyte
concentration is
usually a sign of a
viral infection
Eosinophil 0.0-0.04% 0.01
Monocyte 0.0-0.05% -
Basophils 0.0-0.01% -
Stabs 0.0-0.04% -

18
Date Request: February 15, 2011

DENGUE DUO TEST

Test Result
NS1 Antigen Positive
IgM Antibody Negative
IgG Antibody Negative

Interpretation
NS1 Positive Indicative of early acute
dengue infection.
IgM Positive Indicative primary dengue
infection
IgG Positive Indicative of secondary or
past dengue infection

19
Date Request: February 15, 2011
8:00am

Hematology
Exam name Normal Values Result
Hemoglobin 110-140 gm/L -
Hematocrit 0.37-0.47 0.42
RBC count 4.5-5x10”/l -
WBC count 4.5-10x10”/l -
Platelet count 150-400x10 120 reduced platelet
count is an
increased risk of
bleeding.

Segmenters 0.50-0.70% -
Lymphocyte 0.20-0.40% -
Eosinophil 0.0-0.04% -
Monocyte 0.0-0.05% -
Basophils 0.0-0.01% -
Stabs 0.0-0.04% -

20
Date Request: February 15, 2011
5:00pm

Hematology
Exam name Normal Values Result
Hemoglobin 110-140 gm/L 140
Hematocrit 0.37-0.47 0.42
RBC count 4.5-5x10”/l 4.7
WBC count 4.5-10x10”/l 3.0 Low white blood
cell count is a
decrease
in disease-
fighting cells
circulating in your
blood.
Platelet count 150-400x10 138 reduced platelet
count is an
increased risk of
bleeding.

Segmenters 0.50-0.70% 0.52

Lymphocyte 0.20-0.40% 0.47 An increase in
lymphocyte
concentration is
usually a sign of a
viral infection
Eosinophil 0.0-0.04% 0.01
Monocyte 0.0-0.05% -
Basophils 0.0-0.01% -
Stabs 0.0-0.04% -

21
Drug Study

NURSING
DRUGS ACTION INDICATION CONTRAINDICATION SIDE EFFECTS
CONSIDERATIONS
Generic Name: Suppresses Short-term Hypersensitivity. Angina, >Assess other
Omeprazole gastric secretion treatment of active Lactation and children. tachycardia, medications patient
by inhibiting duodenal ulcer, Combination therapy bradycardia; may be taking for
Brand Name: hydrogen/potassiu gastroesophageal with clarithromycin palpitation, effectiveness and
Zegerid m ATPase reflux disease should not be used in headache, interactions.
enzyme system in (GERD), including patients with hepatic dizziness, rash,
Classification: the gastric parietal erosive impairment. diarrhea, >Monitor
Gastrointestinal/H cell: characterized esophagitis and abdominal therapeutic
epatobiliary Drugs as a gastric acid symptomatic pain, acid effectiveness and
pump inhibitor, GERD; long term regurgitation, adverse reactions at
Dosage: since it blocks the treatment of nausea, beginning of therapy
20mg final step of acid pathologic vomiting, and periodically
production hypersectory constipation, throughout therapy.
Frequency: conditions; short- flatulence,
OD term treatment of cough, upper >Assess GI system:
active benign respiratory bowel sounds 8
Route: gastric ulcer. infection, hrly, abdomen for
PO asthenia, back pain and swelling,
pain. appetite loss

>Give before patient

eats: patient should
swallow capsule
whole

22
>Do not open,
chew, or crush: may
give with antacids

23
 NURSING
DRUGS ACTION INDICATION CONTRAINDICATION SIDE EFFECTS
CONSIDERATIONS
Generic Name: Long-acting non- Treatment of Hypersensitivity to Somnolence, >Assess for allergy
Cetirizine sedating chronic idiopathic cetirizine or to any of fatigue, symptoms: rhinitis,
antihistamine that urticaria, pruritis, its ingredients or Pharyngitis, pruritus, urticaria,
Brand Name: selectively inhibits eczema, hydroxyzine. Severe dizziness, watering eyes,
Virlix peripheral H1 dermatitis, as renal insufficiency . coughing, before and
receptors. adjuvant therapy Pregnancy and epistaxis, periodically during
Classification: w/ hydrocortisone lactation. Elderly bronchospasm, treatment
Antiallergics external patients. Pedia <6yrs. sore
preparation, Cardiac Disease. throat.Drowsin >Aseess respiratory
Dosage: seasonal and ess, headache, status and increase
1 tab perennial allergic gastrointestinal in bronchial
rhinitis, and (GI) secretions,
Frequency: allergic disturbances. wheezing, chest
OD conjunctivitis. tightness; provide
fluids to decrease
Route: viscosity or
PO thickness of
secretion

>Give without
regard to meals

>Store in tight, light

resistant container

24
 NURSING
DRUGS ACTION INDICATION CONTRAINDICATION SIDE EFFECTS
CONSIDERATIONS
Generic Name: Group of fat Vitamin K is also Hypersensitivity to Pain, swelling, >Assess for
Vit. K soluble vitamins involved in bone Vitamin K or soreness at bleeding
that are needed formation and the injection
Brand Name: for the repair and may site may occur. >Monitor drug
Aqua-Mephyton posttranslational decrease the Temporary Effectiveness
modification of incidence or flushing, taste
Classification: certain proteins, severity of changes, >Assess patients
Dosage: mostly required osteoporosis and dizziness, rapid knowledge about
1 ampule for blood slow bone loss. heartbeat, the drug
coagulation but sweating,
Frequency: also involved in shortness of >Give IV after
Q8° x 3 doses metabolism breath, or diluting with D5NS
pathways in bone bluish 10 ml or more
Route: and other tissue. lips/skin/nails
IV may also >Explain to the
infrequently family the indication
occur. and contraindication
of the drug,

>Instruct patient to
report symptoms of
bleeding

>Advise patient to
not use hard
toothbrush.

25
 NURSING
DRUGS ACTION INDICATION CONTRAINDICATION SIDE EFFECTS
CONSIDERATIONS
Generic Name: Suppresses Short-term Hypersensitivity. Angina, >Assess other
Omeprazole gastric secretion treatment of active Lactation and children. tachycardia, medications patient
by inhibiting duodenal ulcer, Combination therapy bradycardia; may be taking for
Brand Name: hydrogen/potassiu gastroesophageal with clarithromycin palpitation, effectiveness and
Prilosec m ATPase reflux disease should not be used in headache, interactions.
enzyme system in (GERD), including patients with hepatic dizziness, rash,
Classification: the gastric parietal erosive impairment. diarrhea, >Monitor
Gastrointestinal/H cell: characterized esophagitis and abdominal therapeutic
epatobiliary Drugs as a gastric acid symptomatic pain, acid effectiveness and
pump inhibitor, GERD; long term regurgitation, adverse reactions at
Dosage: since it blocks the treatment of nausea, beginning of therapy
40mg final step of acid pathologic vomiting, and periodically
production hypersectory constipation, throughout therapy.
Frequency: conditions; short- flatulence,
OD term treatment of cough, upper >Assess GI system:
active benign respiratory bowel sounds 8
Route: gastric ulcer. infection, hrly, abdomen for
IV asthenia, back pain and swelling,
pain. appetite loss

26
Nursing Care Plan

Name: A.S.
Age: 16 years old
Medical Diagnosis: Dengue Fever

Nursing Diagnosis: Bleeding related to altered clotting factor

Short term goal: After 1 hour of nursing intervention, the client will be able to demonstrate behaviors that reduce the risk
for bleeding

Long term goal: At the end of the confinement, the patient will no longer experience bleeding.

Cues Problem Scientific Intervention Rationale Evaluation

Rationale

Subjective cues: Bleeding Bleeding in − Assess for − The G.I Goal met. The
dengue is one of signs and tract client was able to
“Nung paghawak ko the dreaded symptoms (esophagus demonstrate
sa ilong ko parang complications and of G.I and rectum) behaviors that
basa tapos nung is associated with bleeding. is the most reduces the risk
tiningnan ko dugo higher mortality in Check for usual for bleeding.
na” as verbalized dengue secretions. source of
by the patient. hemorrhagic fever Observe bleeding of
color and its mucosal
consistency fragility.
Objective cues: of stools or
− Body vomitus

27
 weakness
− Dry lips − Focus for − To prevent
− Dry skin presence of other
− Facial bleeding complicatio
grimace from one or ns
- Vital signs more sites
taken as
follows:
Temp: 37.2 − Monitor − An increase
BP: 90/60 pulse and in pulse
PR: 93 blood with
RR: 18 pressure decreased
blood
pressure
can indicate
loss of
circulating
blood
volume.

− Note − Changes
changes in may
level of indicate
consciousn cerebral
ess perfusion
secondary
to
hypovolemi
a and
hypoxemia.

28
− Encourage − In the
use of soft presence of
toothbrush, clotting
avoiding factor
straining for disturbance
stool and s, minimal
forceful trauma can
nose cause
blowing mucosal
bleeding.

− Increase − To prevent
fluid intake dehydration

29
Name: A.S.

Medical Diagnosis: Dengue Hemorrhagic Fever

Nursing Diagnosis: Acute pain related to the present condition

Short Term Goal: After nursing intervention, patient’s pain scale of 5 out of 10 will decrease to 2.

Long Term Goal: At the end of confinement, patient will be free from pain.

Cues Problem Scientific Reason Intervention Rationale Evaluation

Subjective Acute pain Dengue fever also Independent: Goal met.

cues: known as breakbone Patient’s pain
fever, is an - Establish rapport - To gain trust and scale of 5 out
“Masakit yung acute febrile infectiou cooperation of 10
ulo at katawan s disease caused by decreased to
ko.”as the dengue virus. -Heart rate, blood 2.
verbalized by Typical symptoms -Monitor skin color and pressure,
the patient. include headache, a vital signs. temperature and
characteristic skin respiration are
rash, usually altered in
Objective and muscle and joint acute pain.
cues: pains; in a small
-pain scale of 6 proportion the -Provide comfort
out of 10 disease progresses measure such as touch, - To promote
to life-threatening repositioning and use of nonpharmacological

30
- Febrile complications such heat or cold packs. pain management
T: 37.7 Cº as dengue
hemorrhagic - Instruct in and -To distract attention
- Body fever (which may encourage use of and reduce tension
weakness lead to relaxation techniques
severe hemorrhage) such as focused
- Restlessness and dengue shock breathing, imaging and
syndrome (where CD tapes.
a very low blood
pressure can cause -Encourage diversional -To divert the pain
- Facial organ dysfunction). activities such as and to promote
grimace watching TV, listening to nonpharmacological
http://en.wikipedia.or radio and socialization to pain management.
- Flushed skin g/wiki/Dengue_fever others.

- Dry lips -Eliminate additional Patients may

stressors or sources of experience an
discomfort whenever exaggeration in pain
possible. or a decreased ability
to tolerate painful
stimuli if
environmental,
intrapersonal, or
intrapsychic factors
are further stressing
them.
Dependent
-Administer analgesic as -Analgesic is a pain
indicated reliever. It is
indicated for
moderate to severe

31
 pain.
Name: A.S.

Medical Diagnosis: Dengue Hemorrhagic Fever

Nursing Diagnosis: Hyperthermia related to invasion of infection and stimulation of nociceptors

Short Term Goal: After nursing intervention within the shift, patient’s temperature of 37.7 Cº will decrease to 37 Cº

Long Term Goal: After the confinement, patient will demonstrate behavior to monitor and promote normothermia.

Cues Problem Scientific Intervention Rationale Evaluation

Reason

Subjective cues: Hyperthermia Infectious agents Independent: Goal met.

(Pyrogens) Patient’s
“Masakit ang ulo stimulates - Establish rapport - To gain trust temperature of
ko.” As verbalized monocytes which and cooperation 37.7 Cº decreased
by the patient. releases to 37 Cº.
pyrogenic - Provide TSB - To promote heat
Objective cues: cytokines. loss by
Pyrogenic evaporation and
- Febrile cytokines conduction
T: 37.7 Cº stimulates
Anterior - Monitor vital - For baseline
- Body weakness hypothalamus signs especially data and to note
which results to temperature q1 changes in
- Restlessness elevated temperature
thermoregulatory
- Facial grimace set point. It leads - Monitor intake - To assess

32
 to increased heat and output potential fluid and
- Flushed skin reservation electrolyte loses.
(vasoconstriction)
- Dry lips and increased
heat production - Encourage - To replace fluid
Temp: (involuntary increase fluid lost through
musclular intake insensible water
contractions) losses and
resulting to fever. sweating

- Remove - To promote heat

excessive clothing loss and surface
or blankets cooling by
conduction and
radiation

- Provide air - To replace fluid

cooling lost by convection
environment like
use of fan

- Limit visitors and - to reduce

bed rest oxygen
consumption and
metabolic
demands
Dependent:

- Administer - Medication helps

antipyretic as to facilitate faster
ordered by the recovery.

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physician

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