NORTH EASTERN COLLEGE

COLLEGE OF NURSING

CASE STUDY ON THE NURSING

CARE OF CHILD WITH
DENGUE HEMORRAGIC FEVER
In Partial fulfillment
of the requirements for the course
NC119-A Care for Mother and Child Adolescent Nursing

Submitted By:
Group 1
Precious P. Estrada
Wilshen Domingo
Rhonilyn Garcia
Charlot Agustin
Shan Cai Campos
Aiza Ogano
Mary May Mercado
Kaycee Aquino
Maria Lane Paclibare

1
OCTOBER 24, 2022

Mr. Ariel Cabanilla

Clinical Instructor,
Northeastern College City

Dear Asst. Prof Ariel:

We Second year students of North Eastern college, College of Nursing, would like to ask your
permission to presence the case of patient V., who was admitted for dengue hemorrhagic fever
on October 12-2022, at Flores Memorial Medical Center in partial fulfillment of the
requirements in NC119-A Care for Mother and Child Adolescent Nursing.
This study is essential to expand our knowledge, enhance our skill and gain a positive attitude in
providing quality and holistic care.

We will assure to you that patient’s confidentiality will be kept, and all date gathered will be
used for educational purposes only. We hope for your kind approval.

Respectfully yours,

BSN 2-A Group 1

Precious P. Estrada
Wilshen Domingo
Rhonilyn Garcia
Charlot Agustin
Shan Cai Campos
Aiza Ogano
Mary May Mercado
Kaycee Aquino
Maria Lane Paclibare

2
 TABLE OF CONTENTS

ACKNOWLEDGEMENT…………………………………………………………………………
…………………4
INTRODUCTION…………………………………………………………………………………
……………………5
OVERVIEW………………………………………………………………………………………
………………………..6-8
DEMOGRAPHIC
DATA……………………………………………………………………………………………..9
HISTORY OF PRESENT, PAST AND FAMILY
HISTORY………………………………………...10
PHYSICAL
ASSESSMENT……………………………………………………………………………………
…….11-14
GORDONS1………………………………………………………………………………………
………………………..5-17
COURSE IN THE
WARD…………………………………………………………………………………………..16-
20
LABORATORY AND
DIAGNOSTICS……………………………………………………………………….21-23
ANATOMY AND
PHYSIOLOGY……………………………………………………………………………….22-37
PATOPHYSIOLOGY……………………………………………………………………………
…………………….38-42
DRUG
STUDY……………………………………………………………………………………………
………………43-47
NURSING CARE
PLAN………………………………………………………………………………………………
48-50
DISCHARGE
PLANNING………………………………………………………………………………………
……51

3
 ACKNOWLEDGEMENT

This case study of our patient has greatly helped us in gaining more knowledge and skills in the
field we have choose. This would not have been possible if not for the people who have been
very kind enough to render their time, concern, and support. We would like to express our
gratitude to: First, we would like to thank God Himself and His sovereign activity, His guidance,
protection and control over the whole rotation. To our dearest parents who supported us from the
beginning to achieve our dreams to become registered nurses someday. We would like to thank
Mrs. Kathleah, for being so supportive, compassionate, and understanding towards us. For the
brilliant authors of the books and articles who provided us significant information regarding our
case and to the Silliman Library and Learning Resource Center who provided us the access to the
books we needed. To the Staff of FMMC, from the physicians, nurses, and nursing aids, we
thank you for aiding us and making our pediatrics experience full of learning. For the time they
had spared for us which enable us to gain more knowledge and
skills and gave us the opportunity to meet our patient who is the subject of this case study. We
are so honored to have worked with them and praise for their passion for being a health care
personnel.
To our friends who encouraged and gives us suggestions in making this paper we completed.
And last but not the least, we extend our deepest gratitude to our patient for trusting us and being
with us through the experience. We would not have a case to study. Thank you for opening up
yourself to us, and for letting us learn from your case.

4
 INTRODUCTION

Dengue Fever Dengue fever is a mosquito borne tropical disease caused by the
dengue virus. Symptoms typically begin three to fourteen days after infection. This
may include a high fever, headache, vomiting, muscle and joint pains, and a
characteristic skin rash. Recovery generally takes two to seven days. In a small
proportion of cases, the disease develops into the life-threatening dengue
hemorrhagic fever, resulting in bleeding, low levels of blood platelets, and blood
plasma leakage, or into dengue shock syndrome, where dangerously low blood
pressure occurs. Dengue is spread by several species of mosquito of the Aedes
type, principally A. aegypti. The virus has five different types; infection with one
type usually gives lifelong immunity to that type, but only short-term 10
immunity to the others. Subsequent infection with a different type increases the
risk of severe complications. Several tests are available to confirm the diagnosis
including detecting antibodies to the virus or its RNA.A novel vaccine for dengue
fever has been approved and is commercially available in several countries. Other
methods of prevention are by reducing mosquito habitat and limiting exposure to
bites. This may be done by getting rid of or covering standing water and wearing
clothing that covers much of the body. Treatment of acute dengue is supportive
and includes giving fluid either by mouth or intravenously for mild or moderate

5
disease. For more severe cases blood transfusion may be required.[2] About half a
million people require admission to hospital a year. Nonsteroidal anti-
inflammatory drugs (NSAIDs) such as ibuprofen should not be used. Dengue has
become a global problem since the Second World War and is common in more
than 110 countries. Each year between 50 and 528 million people are infected and
approximately 10,000 to 20,000 die. The earliest descriptions of an outbreak date
from 1779. Its viral cause and spread were understood by the early 20th century.
Apart from eliminating the mosquitoes, work is ongoing for medication targeted
directly at the virus. It is classified as a neglected tropical disease.

Overview of the Disease

Dengue Hemorrhagic Fever (DHF) is one of the most common mosquito-borne virus
diseases that occurs in tropical and sub-tropical countries in the world. The first and second
recorded epidemic of Dengue Hemorrhagic Fever in South East Asia was in Manila in the year
1954 and 1956 followed by the third epidemic which happened in Bangkok, Thailand in 1958.
Today, severe dengue affects most Asian and Latin American countries and has became the
leading cause of hospitalization death among children and adults in these regions.
Dengue is cause by virus Flaviviridae family and has four distinct, but closely related
serotypes of virus that cause dengue : DENV-; DENV-2; DENV-3; and DENV-4. It is
transmitted to humans by a bite of mosquito called Aedes Aegypti. Infections with any of the
four
serotypes can cause clinical symptoms that may vary in virus virulence, and host response.
Recovery from the infection believed to provide life-long immunity against that particular
serotype. However, cross-immunity to the other serotypes increase the risk of developing severe
dengue. Dengue has its progression from Dengue Fever, which is a simple form of dengue and it
may lead to dengue hemorrhagic fever, a condition which involves sensitive stomach,
petechial(pinpoint rashes), weak pulse, and internal bleeding that can lead to black vomit or
stools. If dengue hemorrhagic fever is left untreated, it will lead into Dengue Shock Syndrome. A
worst form of dengue that can also result death.
According to the WHO (World Health Organization), the amount of recorded dengue
cases has grown dramatically around the world in the past decades. Majority of these cases are

6
asymptomatic or mild and self-managed, hence the actual number of dengue cases are under-
reported. Many cases also diagnosed as other febrile illness.
An estimation indicates 390 million dengue virus infection per year, of which 96 million
manifest clinically (with any severity of the disease). Another study of prevalence of dengue
estimates that 3.9 billion people are at risk of infection with dengue viruses. Despite a risk of
infection in 129 countries, 70% of the actual burden is in Asia.
The number of cases reported to WHO increase over 8 folds over the last decades from
505,430 in 2000, to over 2.4 million in 2010 and 5.2 million in 2019. Reported deaths from year
2000 up to 2015 increased from 960 to 4032, affecting mostly the younger age group. By the
year 2020 up to 2021, the cases seemingly decreased as well as the reported deaths. However,
the data are not yet complete and COVID-19 pandemic might have delayed the reporting in
several countries.

Mode of Transmission:
1. Bite of an infected mosquito, especially Aedes Aegypti
Aedes Aegypti is a day-biting mosquito, they usually appear two hours after the sunrise and two
hours before the sunset.

• The always bread in areas with stagnant water (eg. Rain water, waters that
remained after flooding, natural bodies of water).
• Has limited and low flying movement.

• Has fine whole dots on the wings and white bands on the legs.
2. Aedes Albopictus may contribute to the transmission of the dengue virus in rural areas.
3. Other factors that may contribute:
• Aedea polynensis
• Aedes Scutellaris simplex

Incubation Period:
• 3-14 days, commonly 7-10 days.
Period of Communicability:
1. Patients are usually uninfected to the mosquito from the day before the febrile period to
the end of it.
2. Mosquito becomes infective from day 8 to 12 after blood meal and remains infective
throughout its life.
Source of Infection:
1. Infected persons – the virus is present in the blood of the patient during the acute phase
of the disease and will become a reservoir of the virus, blood sucked by mosquitos which
may transmit the virus.
2. Stagnant Water – any stagnant water in the household like imbak na tubig sa may
sirang gulong,plant pots or vases are usually the breeding sites of mosquitos.
Dengue Hemorrhagic Fever
A severe form of dengue virus infection with symptoms of fever, hemorrhagic diathesis,

7
hepatomegaly, and hypovolemic shock.

Classification According to Severity of the Disease:

1. DENV -1: Symptoms are fever accompanied with non-specific symptoms and
only hemorrhagic manifestation is present in the tourniquet test.
2. DENV-2: All symptoms of DENV-1 are present with additional spontaneous
bleeding in the nose, gums and gastrointestinal tract.
3. DENV-3: Presence of cardiac failure is noted as manifested by weak pulse,
narrow pulse, hypotension, cold, clammy skin, and restlessness.
4. DENV-4: Profound shock is noted, undetectable blood pressure and pulse is also
present.

Compilations:
1. Dengue Fever
a. Epistaxis (nose bleeding), menorrhagia (menstruation bleeding for more than 7
days)
b. GI bleeding
c. Peptic ulcer

2. DHF
a. Metabolic Acidosis – build-up of acid in the body due to kidney disease or kidney
failure.
b. Hyperkalemia – increase potassium level in the blood.
c. Tissue anoxia – absence of oxygen to organ’s tissue although there is adequate
blood flow to the tissue.
d. Bleeding into the CNS or adrenal glands
e. Uterine bleeding may occur
f. Myocarditis – inflammation in the heart muscle (myocardium).
3. Severe manifestation
Dengue encephalopathy is manifested by increasing restlessness, apprehension or
anxiety, disturbed sensorium, convulsion, spacity and hyporeflexia (skeletal muscle or have
decrease or absence on reflex)

8
 DEMOGRAPHIC DATA

Patient’ Profile
Name: Mr. V
Address: Buenavista, Santiago City, Isabela Philippines 3311
Gender: Male
Birthday: March 15, 2013
Age: 9 y/o
Birthplace: Divisoria, Santiago City, Isabela
Nationality: Filipino
Civil Status: Single
Religion: Ispiritista
Educational Attainment: Elementary Student (Grade 4)

9
Allergies: None

Admitting Time: 6:49 pm

Admitting Date: October 12, 2022
Admitting Diagnosis: Dengue Fever
Physician In Charge: Dra. Gemma Cristobal
Chief Complaint: Nausea and Vomiting, Fever

HISTORY OF ILLNESS
Past Medical Health History of the Patient:

*According to the patient’s significant other, the patient had never experience
cough,
cold, fever, chicken pox, or any childhood illnesses before.
*The patient has no history of hospitalization, but the patient seeks medical advice
or
consultation to the barangay health center.
*The patient had no history of allergies, no history or involvement in any
accidents.

Present Medical Health History:

*Two weeks prior of admission the patient has urinary tract infection or UTI.
10
 * One day prior to the patient was experiencing fever, loss of appetite so the
guardian
decided to take him to Flores Medical Memorial Center.
* October 12, 2022, at 6:49 PM, the patient was admitted experienced nausea and
vomiting. The patient also has fever.
*After the day of admission, the patient

PHYSICAL ASSESSMENT
AREA METHOD FINDINGS POST FINDINGS INTERPRETATION
Inspection Head is round, Head is round,
HEAD erect, erect,
normocephalic, normocephalic,
symmetric, No symmetric, No
involuntary involuntary
movement noted. movement noted.
Palpation Head is hard Head is hard
and smooth, (-) and smooth, (-)
lesions, (-) lesions, (-)
masses. masses.
HAIR Inspection The hair is The hair is
black, thick, black, thick,
short and short and
equally equally
distributed, distributed,

11
 (-) dandruff, (-) (-) dandruff, (-)
infestation infestation
Palpation (-) sign of lesion, (-) sign of lesion,
tenderness and tenderness and
nodules while nodules while
palpated. palpated.
FACE Inspection Face is Face is
symmetric and symmetric and
oval, with no oval, with no
abnormal abnormal
orofacial orofacial
movements movements
noted. (-) facial noted. (-) facial
drooping, has a drooping, has a
mole near R mole near R
temporal, L temporal, L
frontal & R frontal & R
upper lips. (-) upper lips. (-)
facial grimace facial grimace
Palpation Bilateral Bilateral
temporal temporal
arteries are arteries are
elastic and not elastic and not
tender when tender when
palpated. palpated.
(-) lesion, (-) (-) lesion, (-)
masses. masses.

SKIN Inspection Good elasticity Good Good elasticity Good the virus
skin skin (arbovirus)
turgor turgor within the blood
No redness No redness vessels,
Hematoma in Hematoma in especially those
the upper right the upper right feeding the skin,
arm. arm. causes changes
to these blood
vessels. The
vessels swell
and leak because
of increase
capillary
permeability. As
the blood vessels

12
 become more
damaged the
blood vessels
start to leak.
When blood
leaves the
circulatory
system and
becomes
stagnant, there is
almost
immediate clotting
palpation (-) masses, (-) (-) masses, (-)
rashes, rashes,
EYES Inspection Good eye reflect Good eye reflect
No tenderness No tenderness
while clossing while clossing
eyè eyè
EARS Inspection Good hearing Good hearing
Auricle Auricle
alignment to the alignment to the
eye eye
NOSE Inspection Nose is same Nose is same
AND color in the face color in the face
SINUSES Good airflow in Good airflow in
each nosestril, each nosestril,
good sense of good sense of
smell smell
palpation (-) no (-) no
tenderness, (-)discharge tenderness,
(-)discharge
MOUTH Inspection Nose is same Nose is same
AND color in the face color in the face
THROAT Good airflow in Good airflow in
each nosestril, each nosestril,
good sense of good sense of
smell smell
NECK Inspection No lesion, No lesion,
symetric, jaw - symetric, jaw -
no swelling, no swelling,
good ROM good ROM

palpation (-) lesion, (-) (-) lesion, (-)

13
 masses masses
Arms, Inspection Nails is round, Nails is round,
Hands pink and pink and
and well trim well trim
finger Arm is good Arm is good
ROM, have ROM, have
hematoma in the hematoma in the
left arm left arm
Posterior Inspection Vestivular sound Vestivular sound
Chest
Anterior Inspection Good skin Good skin
Chest condition, no condition, no
tendernss tendernss

palpation (-) lesion, (-) (-) lesion, (-)

masses masses
Heart
Heart Inspection Good sound, Good sound,
noted s1&s2, no noted s1&s2, no
abnormal abnormal
pulsation pulsation
palpation (-) lesion, (-) (-) lesion, (-)
masses, (-) masses, (-)
tenderness tenderness

14
 11 GORDONS HEALTH PATTERN

BEFORE HOSPITALIZATION DURING HOSPITALIZATION

HEALTH PERCEPTION-
HEALTH MANAGEMENT
Uses over-the-counter Shows interest to recover
PATTERN medications.The patient is fast.
immunized with Covid
Vaccine, BGC, Hepa B,
and
Vitamin K.
NUTRITIONAL-METABOLIC
PATTERN
The patient eats a total of The doctor ordered NPO
3 temporarily for 3hours
meals everyday and
accompanied DAT once there's
with a snack every no
afternoon. persistent vomiting.
She likes to eat vegetables
but not meats. The patient
also drinks 6-8 glasses of
water.
ELIMINATION PATTERN Stool: The patient defecate Stool: The patient
15
 2-3 times daily. The
patient
also explains that his stool
is
brown and formed.
Urination: The patient
voids
3-5 times a day. The urine
color is yellow amber and
there is no pain when
urinating.
ACTIVITY-EXERCISE
PATTERN
The patient walks to their
home after school. He
plays
basketball every sunday.
He
is also able to bathe, eat,
and
walk independently
SLEEP-REST PATTERN patient sleeps at 9pm to
5am and do not have
difficulty in sleeping
COGNITIVE-PERCEPTUAL
PATTERN
The patient is oriented
regarding time, place, and
people. The patient is able
to
respond to stimulus
SELF-PERCEPTION-SELF
CONCEPT PATTERN
The patient believes that
he
is a good person and a
16
defecate
twice daily and has no
discomfort when
defecating.
Urination: Patient voids
3-6
times a day with clear
colored urine. The patient
doesn't experience
pain and
burning sensation during
urination.
The patient became weak
and can't do
anything
because of his IV line. He
needs help to bathe, eat,
and
walk.
At first, the patient had
difficulty in sleeping but
after
a few days, the patient
became comfortable in
sleeping.
The patient is oriented
regarding time, place,
and
people. The patient is
able to
respond to stimulus
The patient had
decreased
self-esteem and his self-
 student because he does image as a student
his lessens
assignments and because he couldn’t do
homework’s. his
activities and
homework’s

ROLE RELATIONSHIP The patient lives with his He is being supported by

PATTERN grandma because his his
father mother financially but his
went AWOL and his Grandma is the one who is
mother is working abroad. taking care of him.
SEXUALITY- Has no history of Has no history of STI/STD.
REPRODUCTIVE STI/STD. No No
PATTERN signs of puberty yet signs of puberty yet.

PATTERN OF COPING Copes up with his Takes a nap and he rests

AND problems when when he is tired
STRESS TOLERANCE by talking and asking for
help
to his grandma.
PATTERN OF VALUE The patient is an Their religion doesn’t
AND Espiritista interfere with the
BELIEF and believes that God will procedures
help him be cured. done.

17
 Course in the Ward
Date and Doctor’s Order
time
10-12-22 Patient admit to ROC under the service of Dr. Gemma M. Cristobal
  Secure consent for admission and management
  TFR Q shift and recorded
  NPO temporarily, for 3hrs the DAT ounce with no persistent vomiting
BP 100/60
HR 132 CBC RAT
RR 26 Urinalysis
Temp. 39.5 IVF D5LR 1L 873 CC x 8hrs then regulate to 77 CC 1hr
 Therapeutics
- Paracetamol 300mg /IV Q4 PRN
- Ranitidine 30mg/IV now
- HNBB %mg/5IVF now
- Metaclopramide 6mg/IV Q8 x 3 doses
- Increase OFI
- VS monitoring Q4 and recorded
-WOF untoward signs and symptoms
- Refer
10-13-2022 -Repeat CBC

18
 - Cefraxene 8AM q 12 (generic)
- Tf: D5LR x 8h
- VS BP q 4
- Ranitidine 25g IV q 8
10-14-2022 - repeat CBC
- Reinsert IVF
- Continuous medication
10-15-2022 -continuous medication
- Repeat CBC in the AM
Same ivf
10-16-2022 - Continuous Medication
- Repeat CBC
10-17-2022 - repeat CBC in AM
- Same IVF

Vital Sign Sheet

10-12-2022 02:00 BP: 90/60 CR/PR: 101 RR: 34 TEMP: 38.4
23:00 BP: 90/60 CR/PR: 122 RR: 28 TEMP: 37.1
05:00 BP: 90/60 CR/PR: 119 RR: 30 TEMP: 37.2 U: 50
10-13-2022 08:00 BP: 100/70 CR/PR: 127 RR: 31 TEMP: 39.4
11:00 BP: 100/70 CR/PR: 123 RR: 28 TEMP: 38.4 U: 240
12:30 - - - TEMP: 39.2
14:30 - - - TEMP: 38.4
17:00 BP: 90/60 CR/PR: 117 RR: 32 TEMP: 39.5 U: 600
10-14-2022 08:00 BP: 100/70 CR/PR: 98 RR: 30 TEMP: 37
11:00 BP: 100/70 CR/PR: 109 RR: 28 TEMP: 36.8
11:30 - - - TEMP: 37.0
17:00 BP: 90/60 CR/PR: 116 RR: 30 TEMP: 36.8
2:00 BP: 100/60 CR/PR: 90 RR: 30 TEMP: 37.8
2:00 BP: 90/60 CR/PR: 90 RR: 22 TEMP: 37.1 U: 300
BP: 100/60 CR/PR: 90 RR: 22 TEMP: 37.9 U: 400
10-15-2022 08:00 BP: 100/60 CR/PR: 106 RR: 28 TEMP: 37.8
11:00 BP: 100/60 CR/PR: 118 RR: 31 TEMP: 39.4

19
 13:45 - - - TEMP: 38:00
17:00 BP: 100/70 CR/PR: 121 RR: 27 TEMP: 37.5 U: 1140
2:00 BP: 90/60 CR/PR: 110 RR: 24 TEMP: 38.3
2:00 BP: 100/60 CR/PR: 108 RR: 23 TEMP: 38.9 U: 300
5:00 BP: 100/70 CR/PR: 101 RR: 23 TEMP: 38.2 U: 200
10-16-2022 08:00 BP: 100/60 CR/PR: 108 RR: 25 TEMP: 37.8
11:00 BP: 100/60 CR/PR: 96 RR: 27 TEMP: 37.6 U: 100
14:00 BP: 90/60 CR/PR: 94 RR: 24 TEMP: 39 U: 500
2:00 BP: 90/60 CR/PR: 110 RR: 23 TEMP: 37.9
2:00 BP: 100/80 CR/PR: 95 RR: 24 TEMP: 37.4 S: 1 U: 300
12:00 - - - TEMP: 39.2
05:00 BP: 100/ 80 CR/PR: 101 RR: 24 TEMP: 36.7

Medication
Ceftriaxone 1g IVNQ12
Ranitidine 25mg NQ8
Paracetamol Lanep 16 Q4 PRN
Metoclopramide 6mg. IV Q8 x3 doses
Hyosine. Buscopan 5mg (Sl VP) now
Ranitidine 30mg IV now
Paracetamol 1 amp. IV Q4 PRN
Ranitidine 25 mg. With Q8
Ceftriaxone 19 IV Q12 GENERIC

IV Fluids

D5LR 1L x 80cclhr
D5LR 1L x 80cclhr
D5LR 1L x 72cclhr

20
TF: D5LR 1L x 80cclhr
D5LR 1L x 80cclhr
D5LR 1L x 80cclhr

Laboratory and Diagnostics

Request Date: October 16, 2022
Age: 9y7m3d
Released Date: October 17, 2022 Time: 4:54

TEST. RESULT. REFERENCE DATA

Hemoglobin. 12.8. (L) 13.00-18.00 g/dl

Hematocrit. 37.7. (L). 40.00-55.00%

RBC count. 4.78. 4.00-6.00×10^6/uL

WBC count. 3.8. (L) 5.00-10.00×10^3/uL

Platelet. 210. 150.00-400.0×10^3/uL

21
MCV. 78.9. (L) 82.50-98.00 fl

MCH. 26.8. 26.10-32.80pg

MCHC. 34.0. 30.70-35.90 g/dL

Segmenters. 50. 50.00-65.00%

Lymphocyte. 45. (H) 25.00-35.00%

Monocyte. 03. 3.00-7.00%

Eosinophils 02. 1.00-3.00%

Request Date: October 14, 2022

Release Date: October 14, 2022
The: 7:20 am

TEST RESULT. REFERENCE DATA

Hemoglobin. 12.3 (L) 13.00-18.00 g/dl

Hematocrit. 36.3 (L). 40.00-55.00%

RBC count. 4.59 4.00-6.00×10^6/uL

WBC count. 4.2. (L) 5.00-10.00×10^3/uL

Platelet. 291 150.00-400.0×10^3/uL

MCV. 79.1 (L) 82.50-98.00 fl

22
MCH. 26.8. 26.10-32.80pg

MCHC. 33.9 30.70-35.90 g/dL

Segmenters. 65 50.00-65.00%

Lymphocyte. 26. 25.00-35.00%

Monocyte. 07. 3.00-7.00%

Eosinophils 02. 1.00-3.00%

Patient Name: Vaquel, Cesar Age: 9Y6M2ED Gender: M

Doctor Name: Cristobal, Gemma M. Room no. General ward

Request date: October 12, 2022 Released Date: October 12, 2022 Time: 9:11pm

TEST RESULT. REFERENCE DATA

Hemoglobin. 13.3 13.00-18.00 g/dl

Hematocrit. 38.7 (L) 40.00-55.00%

RBC count. 5.00 4.00-6.00×10^6/uL

WBC count. 12.3 5.00-10.00×10^3/uL

Platelet. 374 150.00-400.0×10^3/uL

MCV. 77.4 82.50-98.00 fl

23
MCH. 26.6 26.10-32.80pg

MCHC. 34.4 30.70-35.90 g/dL

Segmenters. 84 (H) 50.00-65.00%

Lymphocyte. 10 (L) 25.00-35.00%

Monocyte. 04 3.00-7.00%

Eosinophils 02 1.00-3.00%

Anatomy and Physiology of Pediatrics Child

A. Circulatory System

24
 The heart, blood and the blood vessels of the body constitute the
circulatory system. The
function of the system is the transportation of the blood.

Blood Flow through the Heart

• Deoxygenated blood returns to the heart from all the parts of the body
via superior
(anterior) and inferior (posterior) vena cava to the right atrium of the
heart.
• From the right atrium, the blood is then squeezed through the tricuspid
valve into the
right ventricle.

25
 • From the right ventricle, the blood is pumped through the pulmonary
semilunar valve to
the pulmonary trunk, which divides into the right and left pulmonary
arteries.
• The pulmonary arteries carry the blood to the lungs where it releases
carbon dioxide
and picks up oxygen.
• The oxygenated blood returns to the left atrium of the heart through
four pulmonary
veins.
• The blood is squeezed through the bicuspid or mitral valve into the left
ventricle.
• The left ventricle pumps the blood through the aortic semilunar valve
to the ascending
aorta, which distributes the bloods to all the organs of the body.

The Blood
26
Blood is a specialized connective tissue consisting of a fluid part
called plasma, and the
formed blood cells. The formed blood of cells include the red
blood cells, white blood cells, and
platelets which are produced inside the bone marrow and this
process is called Hematopoieasis.

27
Bone Marrow or also known as Myeloid tissue is a soft, spongy
substance located at the center of
the bone.
Structure:
At the end of the fetal development, bone marrow first develops
in the clavicle. It
becomes active about 3 weeks later. Bone marrow takes over
from the liver as a major
hematopoietic organ at 32-36 week’s gestation. Bone marrow
remains red until around the age of
7 years, as the need for continuous blood formation is high. As
the body age, it gradually
replaces red bone marrow with yellow fat tissue.
In adults, the average amount of bone marrow is about 2.6
kilograms (5.7 pounds) which
half of it are red. Adults have the highest concentration of
active/red bone marrow located at
bones of vertebrae, hips, sternum, ribs and skull as well as at the
metaphyseal and epiphyseal
ends of the long bones of the arms (humerus) and legs (femur
and tibia). Immature blood cells in
the bone marrow are called stem cells or hematocytoblast. Stem
cells can also found smaller
amount in the bloodstreams and this are called peripheral blood
stem cells.

Function of Blood:
28
 • Transport oxygen from the lungs to the cells of the body.
• Transport carbon dioxide from the cells to the lungs for
excretion.
• Transport nutrients, ions, and water from the digestive tract to
cells.
• Transports hormones to target organs and enzymes to the body
cells.
• Transport waste products fro the cells to the kidneys and sweat
glands.
• Transport hormones to target organs and enzymes to body
cells.
• Regulates body pH through its buffers and the water content of
cells.
• Helps regulate normal body temperature and the water content
of cells.
• Helps prevent fluid loss through the clotting mechanism.
• Protects against foreign microbes and toxins through its
combat cells or leukocytes.
The Red Blood Cells:
Red Blood Cells (erythrocytes) – which carry the oxygen to the
tissues. Make up 95% of
the volume of the blood cells. Appears as biconcave disks with
edges that are thicker than the
center of the cell, looking somewhat doughnut-shaped. They do
not have nucleus and are simple
in structure. Composed of a network of protein called stroma,
cytoplasm, some lipid substances
including cholesterol and red pigment called hemoglobin.

29
 i. Hemoglobin- made up of protein called globin, and pigment
called heme.
A healthy man has 5.4 million RBCs/mm³ while a healthy
woman has 4.8
million RBCs/mm³ of blood. Due to menstruation and loss of
blood, some
women need more iron in their diet for the most efficient
transport of
oxygen by their blood.

ii. Hematocrit – also called as packed cell volume which is to

determine because
it involves the packing of all the cells in the blood sample at one
end of a tube.

Type of White Blood Cells:

White Blood Cells (leukocytes) – which helps to fight
infections. Divided into two
subcategories: the granular leukocytes and agranular or
nongranular leukocytes.

1. The granular leukocytes have granules in their cytoplasm

when stained
with Wright’s stain. These are three types:
i. Neutrophils- Have small, pinkish granules and lobed
nuclei that resembles several links of sausage. Make up
60%-70% of WBCs. Increase in Neutrophils means there is
an acute infection to the body.
ii. Eosinophils- which makes up to 2%-4% of WBCs.
30
 Increased Eosinophils means there is an allergic reaction. It
have red granules and two-lobed, dark nuclei.
iii. Basophils – which makes up to 0.5%-1% of WBCs.
Increased in Basophils means there is a chronic infection to
the body. It have fewer granules, which are bluish in tint
and of variable size. It also have large, two-lobed or kidney
shaped nuclei.
2. The agranular or nongranular leukocytes do not show
granules in their
cytoplasm when stained.
i. Monocytes – A very large agranular leukocyte with large,
variably shaped nuclei. Monocytes make up to 3%-8% of
WBCs. Increased in Monocytes also indicates that there is
also a chronic infection in the body.
ii. Lymphocytes – which makes up about 20%-25% of
WBCs. Increase in Lymphocytes indicates that there is a
presence of antibody reaction happening into the body.
Lymphocytes are almost small as RBCs and its nuclei are
sometimes large that they appear to have no cytoplasm.

The Platelets and Clotting Mechanism:

Platelets (thrombocytes) – are smaller cells that helps blood clot.
A very small disk-
shaped, cellular fragments with a nucleus.
When a small blood vessel are damaged, smooth muscle in the
vessel’s walls contract
and this can stop blood loss. But when a larger vessel are
damaged, the constriction of the

31
 smooth muscle in the vessel walls only slows down blood loss
and the clotting mechanism takes
over. A cut in a blood vessel causes the smooth walls of the
vessel to become rough and
irregular. Clotting or coagulation is a complex process that
proceeds in three stages.
In the first stage, the roughened surface of the cut vessel causes
the platelets to aggregate,
or clump together, at the site of the injury. The damage tissues
release thromboplastin. The
thromboplastin causes a series of reaction that result in the
production of prothrombin activator
and these activities require the presence of calcium ions and
certain proteins and phospolipids.
In the second stage, prothrombin is a plasma protein that is
produced by the liver is
converted into thrombin which happens in the presence of the
calcium ions.
In the third stage, another plasma protein, soluble fibrinogen is
converted into insoluble
fibrin. It is the thrombin that catalyzes the reaction that
fragments fibrinogen into fibrin. Fibrin
forms a long thread and acts like a fish net at the site of injury
and forms clot. When the clot
forms, blood cells and platelets gets entangled in the fibrin
threads and the wound stops bleeding.
Clot reaction or syneresis is the tightening of the fibrin clot in
such a way that the ruptured area

32
of the blood vessel gets smaller and smaller, thus decreasing
hemorrhage.

A. Integumentary

The skin is the largest organ of the body and forms the major
barrier between the internal
33
 organs and the external environment. The skin accounts for
toughly 16% of body's weight. As
the body's first line of defense, the skin is continuously
subjected to potentially harmful
environmental agents, including solid matter, liquid, gases,
sunlight and microorganisms.
Although the skin may become bruised, lacerated, burned or
infected, it has remarkable
properties that allow for a continuous cycle of healing, shedding
and cell regeneration. The skin
is composed of three layers, the epidermis (outer layer), the
dermis (inner layer), and the
subcutaneous fat layer.

Epidermis
The Epidermis covers the body and it is specialized in areas to
form the various skin
appendages: hair, nails and glandular structures. The
keratinocytes of the epidermis produce a
fibrous protein called Keratin, which is essential to the
protective function of the skin. In
addition to the keratinocytes, the epidermis has three other types
of cells that arise from its basal
layer: melanocytes the produce a pigment called melanin, which
is responsible for skin color,
tanning and protecting against UV radiation.

Basal Lamina

34
 Also called the basement membrane is a layer of intercellular
and extracellular matrices
that serves as an interface between the dermis and the epidermis.
It provides for adhesion of the
dermis to the epidermis and serves as a selective filter for
molecules moving between the two
layers. It is also a major site of immunoglobulin and
complement deposition in skin disease.
Dermis
The dermis is the connective tissue layer that separates the
epidermis from the
subcutaneous fat layer. It supports the epidermis and serves as
its primary surface of nutrition.
Two layers of the dermis: the papillary dermis and the reticular
dermis are composed of cells,
fibers, ground substances, nerves and blood vessels. The main
component of the dermis is
collagen, a group of fibrous proteins. Collagen represents 70%
of dry skin weight and serves as
the major stress-resistant material of the skin.
Subcutaneous Tissue
It consists primarily of fat and connective tissues that lend
support to the vascular and
neural structures supplying the outer layers of the skin. There is
controversy about whether the
subcutaneous tissue should be considered an actual layer of the
skin.

35
 Sweat Glands

There are two types of sweat glands: eccrine and apocrine.

Eccrine sweat glands transport
sweat to the outer skin surface to regulate body temperature.
Apocrine sweat glands on the other
hand secrete an oily substance. When mixed with bacteria on the
skin surface they produce body
odor.
Sebaceous Gland
They are located over the entire skin surface except for the
palms. soles, and sides of the
feet. They secrete a mixture of lipids. including triglycerides,
cholesterol and wax. This mixture
is called sebum: it lubricates hair and skin. It prevents undue
evaporation of moisture from the
stratum corneum during cold weather and helps to conserve
body heat.
Hair
It is a structure that originates from hair follicles in the dermis.
Most hair follicles are
associated with sebaceous glands, and these structures combine
to form the pilosebacous unit.
Hair Is a keratinized structure that is pushed upward from the
hair follicle. Hair has been found
to go through cyclic phase identified anagen or the growth
phase, catagen or the atrophy phase,
telogen or the resting phase or the no growth.

36
 Nails
Nails are hardened keratinized plates called fingernails and
toenails that protects the fingers and
toes and enhance dexterity. The nails grows out from a curve
transverse groove called nail
groove. The underlying epidermis attached to the nail plate is
called nail bed. Like hair, nails are
the end product of dead matrix cells that are pushed outward
from the nail matrix. Unlike hair,
nails grows continuously rather cyclically unless permanently
damage or diseased.

37
A. MUSCULOSKELETAL

38
 Cartilage
Cartilage is a firm but flexible type of connective tissue
consisting of cells and intercellular
fibers embedded in an amorphous, gel-like material. It has a
smooth and resilient surface and a
weight-bearing capacity exceeded only by that of bone.
Cartilage is essential for growth before and after birth. It is able
to undergo rapid growth while maintaining a considerable
degree of stiffness.
Bone
Bone is connective tissue in which the intercellular matrix has
been impregnated with
inorganic calcium salts so that it has great tensile and
compressible strength but is light enough
to be moved by coordinated muscle contractions. The
intercellular matrix is composed of two
types of substances-organic matter and inorganic salts. The
organic matter, including bone cells,
blood vessels, and nerves, constitutes approximately one third of
the dry weight of bone; the
inorganic salts make up the other two thirds. The organic matter
consists primarily of collagen
fibers embedded in an amorphous ground substance. The
inorganic matter consists of
hydroxyapatite, an insoluble macrocrystalline structure of
calcium carbonate and calcium
fluoride. Bone may also take up lead and other heavy metals,
thereby removing these toxic

39
 substances from the circulation. This can be viewed as a
protective mechanism.
Types of bones:
1. Osteogenic cells - Undifferentiated cells that differentiate into
osteoblasts. They are
found in the periosteum, endosteum and epiphyseal growth plate
of growing bones.
2. Osteoblasts - Bone-building cells that synthesized and secrete
the organic matrix of bone.
Osteoblast also participate in the calcification of the organic
matrix.
3. Osteocytes - Mature bone cells that function in the
maintenance of bone matrix.
Osteocytes also play an active role in releasing calcium in the
blood.
4. Osteoclasts - Bone cells responsible for the reabsorption of
bone matrix and the release of calcium and phosphate from
bone.
Skeletal Joints
Articulations or joints are sites where two or more bones meet to
hold the skeleton together and give it mobility. There are two
types of joints: Synarthroses, which are immovable joints and
diarthroses, which are freely movable joints. All limb joints are
synovial diarthroidal joints, which are enclosed in a joint cavity
containing synovial fluid. The articulating surfaces of synovial
Joints are covered with a layer of avascular cartilage that relies
on oxygen and nutrients contained in the synovial fluid.
Regeneration of articular cartilage of synovial joints is slow and
healing of injuries of ten is slow and unsatisfactory.
40
PATHOPHYSIOLOGY: DENGUE
HEMMORAGIC FEVER

41
42
43
 DRUG STUDY
Name of Drug Dosage/ Mechanism Indication Contraindica Adverse Effect
Frequency/ of tion
Timing/ Action
Route
Generic 1g IV NQ * * Contraindi CNS:
Name: 12, 1q IV Bactericidal: Uncomplicated cate  Headache
Ceftriaxone Q12 Inhibits gonococcal d with  Dizziness
sodium GENERIC synthesis vulvovaginitis. allergy  Lethargy
Brand Name: of * UTI; lower to GI:
Rocephin bactericidal respiratory cephalospo  Nausea
Therapeutic cell tract rins or  Vomiting
class: wall causing gynecologic, penicillins.  Diarrhea
Antibiotics cell bone or Use  Anorexia
Pharmacologic death. joint, intra- cautiously 
class: Third- abdominal, with renal Pseudomembranou
generation skin or failure, s colitis
cephalosporins skin- structure lactation, HEMATOLOGIC:
infection; pregnancy.  Bone marrow
septicemia  Depression- dec.
* Meningitis WBC, platelets, Hct
*Perioperative LOCAL:
prophylaxis  Pain
* Acute  Inflammation of IV
bacterial otitis site
media
* Acute otitis BEFORE:
media  Do Skin testing
into intradermal
area
 Protect Drug
from light
 Do not mix
ceftriaxone with
other
antimicrobial
drug.
DURING:
Using a separate
44
 syringe when giving
the drug
Have Vitamin K
available in case of
hypoprothrombinemi
a occurs
AFTER:

OTHER:
 Superinfections
 Disulfiram-like
reaction with
alcohol.

Generic 25 mg • Inhibits the • Short-term  CNS: confusion,

Name: NQ8, action of treatment Contraindica dizziness, drowsiness,
Ranitidine 30mg IV histamine at of active te hallucinations,
Hydrochloride now, the H2- duodenal d with headache.
Brand Name: 25 amp w receptor site ulcers and allergy CV: ARRHYTHIMAS
Zantac Q8, located benign to ranitidine,
GI: altered taste, black
Therapeutic primarily in gastric ulcers lactation tongue (ranitidine
Class: gastric • Use bismuth citrate only),
Antiulcer drugs parietal cells, cautiously constipation, dark
Pharmacologi resulting with stools (ranitidine
c class: H2- in inhibition impaired bismuth citrate only),
receptor of gastric renal or diarrhea, drug-induced
antagonists acid hepatic hepatitis (nizatidine,
receptor secretion. function, cimetidine), nausea.
antagonists In addition, pregnancy Endo: gynecomastia
ranitidine Hemat:
bismuth AGRANULOCYTOSIS
citrate has APLASTIC ANEMIA,
some anemia, neutropenia,
antibacterial thrombocytopenia.
action against Local: pain at IM site.
H.pylori. Misc: hypersensitivity
reactions
Generic Name: 16 Q4 Antipyretic Temporary  CNS: headache
Paracetamol PRN, 1 Reduces reduction Contraindica  CV: chest pain,

45
Brand Name: amp IV Q4 fever by of fever, te dyspnea,
Tylenol PRN acting temporary d with myocardial damage
Classification: directly on relief of allergy when doses of 5-
Analgesics hypothalamic minor aches to 8g/ day are
(nonopioid) heat- and pains acetaminoph ingested daily for
Antipyretic regulating caused by e several weeks or
center to common n. when doses of
cause cold and  Use 4g/day are
vasodilation influenza, cautiously ingested for 1 yr.
and sweating, headache, with  GI: hepatic toxicity
which sore throat, impaired and failure,
helps toothache, hepatic jaundice
dissipate backache, function,  GU: acute renal
heat. menstrual chronic failure, renal tubular
cramps, etc alcoholism, necrosis
pregnancy,  Hematologic:
lactation methemoglobinemia-
cyanosis; hemolytic
anemiahematuria,
anuria;
neutropenia,
leukopenia,
pancytopenia,
thrombocytopenia,
hypoglycemia.
 Hypersensitivity:
rash, fever.

Generic 6mg  Metoclopromide It is indicated for Contraindicated GI: Nausea,

Name: IV Q8 causes antiemetic treating nausea and in vomiting,
Metoclopromid x3 effects by vomiting in patients patients with diarrhea
e inhibiting with known Nervous
hydrochloride dopamine D2 and gastroesophageal procainamide system:
Brand Name: serotonin 5-HT3 reflux hypersensitivity Drowsiness,
Reglan receptors in the disease or diabetic • Caution is also restlessness,
Therapeutic chemoreceptor gastro paresis by recommended in fatigue,
class: GI trigger zone (CTZ) increasing gastric patients with insomnia
stimulants located in the are motility. It increases existing CVS: Elevated
Pharmacologic postrema of the muscle contractions hypertension or blood
46
class: brain. This action in other cardiac pressure
Dopamine enhances the the upper digestive disease that may Lymphatic:
Antagonists release of tract. This speed up be sensitive to Gynecomastia
acetylcholine, the catecholamine
causing increased rate at which the release.
lower esophageal stomach empties
sphincter (LES) into
and gastric tone, the intestines
accelerating
gastric emptying
and transit through
the gut.
Generic 5mg Its anticholinergic Hyoscine Contraindicate CNS:
name: (SI action exerts a butylbromide d in patients Dizziness,
Hyoscine VP) smooth-muscle (scopolamine with pyloric anaphylactic
butylbromide now relaxing/spasmolyt butylbromide) obstruction, reactions,
Band name: ic effect. Blockade [Buscopan/Buscapin paralytic ileus, anaphylactic
Buscopan of the muscarinic a] is an and in patients shock,
Drug Class: receptors in the GI antispasmodic drug with prostatic increased ICP,
antispasmodic tract is the basis indicated for the hypertrophy or disorientation,
for its use in the treatment of urinary restlessness,
treatment of abdominal pain bladder neck irritability,
abdominal pain associated with obstruction, drowsiness,
secondary to cramps induced by since it may headache
cramping. gastrointestinal (GI) lead to urinary GI:
Hyoscine spasms. retention in Xerostomia
butylbromide also these patients DERM:
binds to nicotinic Flushing,
receptors, which Dyshidrosis
induces a
ganglion-blocking
effect.

NURSING CARE PLAN

47
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUAT
Subjective Data: Risk for injury Short Term: >establish report. >to secure the trust and Short Term:
related to abnormal Within 4 hours cooperation between the
blood profile as of nursing >monitor vital signs nurse and After 6 hours
evidenced by intervention the the patient. nursing interv
decrease platelet patient will be >perform physical tion
Objective Data: count from 200 to able to: assessment. >serve as the basis for the patient wil
Vital Signs 185. any alteration in lightly
Temp 36.6 Demonstrate >observe for sign of any system functions. improve.
BP 100/60 behaviors, petechiae epistaxis and
PR 93 bpm lifestyle any site of bleeding. >to know the normal Long Term:
RR 20 bpm Change to and abnormality
reduce risk >monitor the platelet assessment of the After 24 hours
Patient in weak factors and count/blood test result. patient. patient
appearance. protect self from will totally
possible injury. >provide comfort and >observing those signs Improve.
Capillary refills in 3 safety by maintaining will help to reduce the
seconds. Long Term: the bed in its lowest risk for injury.
position.
Hematoma in the right >to know if
arm. >advice SO that those there is possible
sharp or self-inflicting bleeding within the
Platelet count result objects may cause internal extremities of
decrease from 200 to injury and should be the patient.
185. keep.
>to ensure patients
>encourage SO not to safety and comfort.
leave the patient.
>to prevent possible or
further injury to the
patient.

>leaving the patient

unattended/unsupervised
may cause anxiety to the
patient and possible
injury may happen.

ASSESSMENT DIAGNOSI PLANNING INTERVENTIO RATIONALE EVALUATION

48
 S N
Altered body Short Term: Independent: >to assists with Short Term:
Subjective Data: temperature After 1 hour measure to reduce
related to of nursing >Monitor vital body temperature. The goal is partially
“Mainit siya na ng disease intervention signs met Because the
hihina” as verbalized process as the >to helps in lowering patient fever is
by the guardian evidenced by temperature >provide tepid the body temperature decrease and not
temperature of the patient bath. and alcohol cool dehydrated
of patient is will decrease skins too rapidly
37.9 from 37.9 to >remove excess causing shivering.
37.5. clothing and Long Term:
covers. >increase metabolic
Objective Data: rate and body
Vital signs: Long Term: >promote a well- temperature.
Temp 37.9 After 48 ventilated area to
BP 100/60 hours of patient. >to decrease warmth
PR 93 bpm nursing and increase
RR 20 bpm intervention >advise patient to evaporative cooling.
the increase oral fluid
Flushed skin intake. >to promote clear
temperature
Weakness flow of air in the
will totally
Dehydration >maintain bed rest patient’s area. One
decrease.
Loss of appetite way of promoting
heat loss.

>to help prevent

elevated temperature
Dependent: associated with
dehydration.
Prescribed oral
medicine

ASSESSMENT DIAGNOSI PLANNIN INTERVENTIO RATIONAL EVALUATION

S G N E
49
Subjective Data: Deficient fluid Short Term: Independent: >to prevent
volume related dehydration.
“Nag suka ako ng to volume loss After 3 hours >monitor patient
tatlong beses.” As due to Of nursing fluids >
verbalized vomiting. intervention, >
the patient will >monitor vital signs
now decrease
vomiting. >instruct the patient to
take rest.

Objective Data: >

Vital Signs
Temp 36.6
BP 100/60
PR 93 bpm Dependent:
RR 20 bpm
>administer
Vomiting medication prescribed
Poor appetite by the physician.
weakness

50
 DISCHARGE PLANNING

MEDICATION
•Patient is instructed to take his medication at home as prescribed by his physician.
•Explain the purpose of the medication/medicine and the importance of taking the medication
properly.
EXERCISE
•Instruct the patient to walk every morning at least 20-30 minutes as his form of exercise but
make sure that the patient has no pain and difficulty of breathing.
TREATMENT
•Encourage the patient to visit a health center or if there is a follow up check-up make sure to
inform him for his next visit in his physician for evaluating the progress of his condition.
HYGIENE
•Encourage the patient to have a good hygiene by taking a bath everyday, mouth care and etc.
•Inform the family of the patient to assist the patient in performing his activities of daily living.

OUTPATIENT
•Inform the patient about his schedule in visiting his physician for follow up check-ups.
DIET
• Patient is instructed regarding his diet; eat nutritious food and increase fluid intake for at least
2.4 L.
•Patient also informed about the importance of having a good diet for treating her disease.
SPIRITUAL
•Patient was instructed to communicate with God by praying asking for guidance, good health
and also don't forget to thank for all of his good deeds.

51
52