MAPANDI MEMORIAL EDUCATIONAL AND MEDICAL COLLEGE

Marawi City
PHYSICAL ASSESSMENT
NAME OF STUDENT: GROUP-1 SCORE:
AREA OF ASSIGNMENT: MALE WARD- 1 CLINICAL INSTRUCTOR: Mrs. Alia A. Saidar R.N.
DATE OF SUBMISSION: May, 21 2024
ADMISSION DATE: May 15, 2024__
PATIENT’S PROFILE
Name: X Age:24 Sex:Male Status: Single
Address: Taraka LDS Religion: ISLAM
HEALTH HABITS
Frequency Amount Period/Duration
1. Tobacco daily 1 pack since 15 years old
2. Alcohol × × ×
3. OTC drugs/non-prescription drugs paracetamol (PRN) 500mg occasional
A. Chief Complaints: fever, headache and body weakness
B. History of Present Illness: (location, onset, intensity, duration, aggravation and alleviation, associates symptoms, previous treatment and result, social and vocation,
responsibilities and diagnosis.)
- A case of 24 Y/O male, single, Muslim presently residing at Taraka LDS. The patient feels remittent fever and headache begun in five days Prior to admission severity on MAY
8, 2024 recur with no pattern and last on May 9 2024 at 6am the patient experiencing fever and severe headache started on May 7 2023 and alleviates his pain when he takes
OTC drugs. Associated with symptoms of headache and body weakness, his treatment was paracetamol for pain reliever. After admission May 15, 2024 and hours passes
patient was diagnosed with Dengue Fever.
C. History of Past Illness: (no previous hospitalization, injuries, procedures, infectious diseases, immunization/health maintenance, major illness, allergies, medications,
habits, birth and developmental history, pattern of sleep, exercise and nutrition.)
- The patient was hospitalized in Tamparan District Hospital with case of fever and headache, no injuries encountered, no procedure done and no infection disease, the patient
didn’t undergo any kind of immunization. No major illnesses nor allergies. Patient takes OTC medicine such as paracetamol. Patient daily habit is listening to music. He used to sleep
at 8 Pm and wake up at 7 to 8 Am. Patient pattern of sleep is 7-8 hour at night. Basketball/ walking is considered his exercise. Patient eats rice and vegetables.
 D. Family History with Genogram

Male
Female

Patient
Acquired diseases: Heredo – familial Diseases:
DENGUE x FEVER
E. Present Illness:
- “Igira a pkagda akn sa ginawa akn a di ako phakapiya na sie akn ipanarig a ginawa akn ko Allah ka In sha Allah na kada gya maggdam akn a
mayaw ago sakit a ulo” as verbalized by the patient.
Hospital Environment: :
- “Sii sa hospital na panalamatan akn so mga nurse ago doctor ka bgan ako iran sa bulong a ipakapiya ginawa akn ago In sha Allah na mapita odi
na isa gawie na phakaliyo ako dun ka miyakapiya akodun”.
F. Summary of Interaction
- The patient is cooperative and responsive. He maintained eye to eye contact and answering question clearly.
 REVIEW OF SYSTEM
Name of Patient: Patient X Vital Signs:
Temperature: 36.6°C Height: 173 CM
Pulse: 61 bpm Weight: 50KGS
Respiration: 20 bpm Blood Pressure: 120/70 mm/Hg
Observation: Received patient lying on bed in a comfortable position, conscious, alert, awake, oriented to time, place & event, w/ an ongoing IVF #D5LR, 1000mL with 400
mL remaining regulated at 30 gtts/min, hooked at left arm, infusing well. The patient used malong to covered his body. He was poorly groomed and was draped with a
Malong. He has brown complexion & black hair.

Received patient lying on bed in a comfortable position, conscious, alert, awake, oriented to time, place & event, w/ an ongoing IVF
1. GENERAL D5LR, 1000mL with 400 mL remaining regulated at 30 gtts/min, hooked at left arm, infusing well. The patient used malong to covered
his body. He was poorly groomed and was draped with a Malong. He has brown complexion & black hair.
H- Head is normocephalic, symmetrical, no Lesion, no Mass, no Tenderness, no Lice, has Dandruff, Scalp color is white.
Facial expressions symmetrical, and no abnormalities was noted as the patient raised and lowered her eyebrows, frowned, closed eyes
tightly, smiled, and showed his teeth. Hair length is 2cm, moist, the color is black and thin with moderately thick density. Hair was evenly
distributed on the scalp.
2. HEENT E- Eyebrows were symmetric, yellowish and arched in shape, evenly distributed, black in color, smooth, and thin with slightly thick
density. Eyelashes is straight and facing outward. Sclera was pale white in color with pinkish-red inner lining of eyelid. no masses, no
lesions, no redness, and no edema. No discharges were noted. Symmetric eyes shape was noted with irises dark brown in color. Pupils
were constricted. Patient did require eyeglasses to read, and eyes could not see clearly. Normal blinking was noted upon testing the
corneal reflex with a cotton wisp. Pupils were equal with round, reactive to light (pupils constrict before light and dilate when light was
pulled away
E- Ears were is in normal in shape, symmetric, no lesions, no masses, no tenderness, no discharges. No Tenderness and right and left
pina were elastic. No tenderness and swelling on the mastoid process were noted. The patient was able to repeat the phrase
whispered to him, out of his sight and 2 feet away from him. He could hear equal sound in both ears in Weber test and Rinne test.
N- Nose were clear with no discharges, no lesion, no tenderness, and no masses. Nasal septum was aligned at the middle. No Nasal
flaring noted. Both nares were patent and could smell properly. Patient was able to identify what he smelled when his eyes were
closed. No tenderness upon palpation on maxillary and frontal sinuses.
T- Trachea was midline upon palpation. no deformity, no lesions, no masses, no lumps, no swelling, no tenderness were noted upon
 palpation. no jugular vein distention, no difficulty in swallowing noted. Patient was able to move his head up and down, side to side, and
shrug his shoulder against resistance. No tenderness and masses were noted when palpating the lymph nodes

3. Integumentary Hair color is black. The Scalp color is white. No presence of dandruff. Lips were dark in color and dry. Patient has brown complexion
which was not dry. Nails from upper and lower phalanges were trimmed with nail beds that were pale pink in color with capillary refill of
<2 seconds. Skin has good skin turgor of 1 second upon gently pulling the bilateral lower forearms and lower legs as well as over the
front of the chest below the collar bone. No Tenderness and no redness. The patient is warm to touch.
Respiratory rate was 20bpm, with 96% O2Sat. Patient doesn’t fell shortness of breath. no deformities on chest, normal symmetric
4. Respiratory bilateral chest expansion. No nasal flaring and no help of accessory muscle to breathe.
The patient itself used to have a tobacco for about 15 years up until now.

Pulse rate was 61 bpm upon palpation of the right radial pulse, with 100/70 mmHg. Pulse rate had regular rhythm with the expected
5. Cardiovascular amplitude. Normal S1 and S2 heart sounds, rhythm, and quality with no heart murmurs heard upon auscultation. No bruits were heard
on the carotid artery and abdominal aorta.

Lips are dark. No visible lesions. Complete teeth up and down. No soreness present, and tongue is moist. Mucosa and gums are dark in
6. Digestive color. Hard and Soft palate are in normal shape and color. His ovula is in the midline upon inspecting. No difficulty of swallowing and
mastification upon asking the patient. The patient had not defecated since the day he admitted. The color of his abdomen is normal in
terms of color, no presence of scars and lesions.
7. Excretory The patient had no excessive sweat and usually urinates 7 times a day with transparent yellow in color. No burning sensation and pain
upon urination. The patient used chamber pot with the assistance of his SO. The patient had not defecated. No history of kidney
problems.

8. Musculoskeletal The patient arms and thighs are equal in size in both sides of body upon assessing him. The patient can able to sit and move his arm
slowly. Body weakness noted. He cannot walk without assistance. The patient’s body is proportional and no deformities was noted.
Muscles is nontender and no atrophy. No sensation of numbness all throughout noted.
 9. Nervous The patient is awake and oriented to time and place, person and can answer question properly. The patient has a good sense of smell,
taste hearing. The patient visual is okay upon assessing him . The 11 cranial nerves were active.

10. Endocrine There is no presence of excessive sweating. He usually urinates 7 times a day. No presence of goiter and no neck mass noted. The
patient has no cold and hot intolerance. No presence of edema noted. No history of Diabetes. No sign of thyroid enlargement. No vitiligo
noted in face, neck, and extremities.

NURSING ASSESSMENT II
Name of Patient: X Age: 24
Chief Complaint: Fever in 5days and Headache Sex: M
Impression / Diagnosis: Dengue fever Inclusive Dates of Care: May, 15 2024
Diet: DAT Allergies: NONE
Type of Operation: NONE

Normal Pattern Before Hospitalization Clinical Appraisal

1. Activities – Rest
a. Activities
b. Rest
c. Sleeping Pattern
2. Nutritional – Metabolic
a. Typical Intake
According to the client, he is
always playing basketball with his
friends and playing mobile games.
According he is a g10 student, he is
starting to sleep at 8pm or 9and
then woke up at 5am.
According to the patient, he
usually eats 3x a day, he can
consume 1 cup of rice with side
Initial
The client has no appetite, doesn’t like to
talk and always closing his eyes since his
head is aching, patient also suffered from
body weakness. Patient sleep at 8pm and
woke up at 7am according to the S.O.
patient consumes 9-10 hours of sleep.
Patient take a nap at morning and also
takes nap at afternoon. Patient ’ s
sometimes distracted because of the other
health care worker and the noise in another
bed.
The client 3x a day but can’t finish his foods,
drinks 1 or half cup of water every meal. he
is on diet as tolerated, during his
Day 1 Day 2
The client is in pain, he suddenly felt
extreme of tiredness and weakness,
clients also suffered severe
headache and hyperthermia.
Patient suffered also from difficulty
of sleeping because of headache.
The client doesn’t have the appetite
to eat because of what his feeling,
patient eats 2x a day as verbalized
 (Food or fluid)
b. Diet dish. Patient drink 1 to 2 cups of by S.O. But still patient consume
c. Diet restriction water every meal he can consume hospitalization he takes medication like, 1.5ML of water each day. His mother
d. Weight 1.5L of water each day. Patient Cetirizine, Tranexamic, Omeprazole, performed a TSB to decrease the
e. Medication/Supplement stated that he doesn ’ t have any Ranitidine, Multivitamins and Paracetamol. body temperature of hyperthermia
food maintenance. clients.
3. Elimination According to the client
he voided urine 5-6 x a The client stated that he The client state that he
a. Urine (frequency, color, transparency) day with a color of urinate 8x a day in a yellow urinates 3x a day in a
yellow to clear. He is to clear color, he also stated yellow color. And stated
b. Bowel (frequency, color, transparency) defecating 2x a day that he have not yet that he defected 2x
with a brown color and defecated with a brown and soft
soft stood stool
4. Ego Integrity According to the client
wife, he doesn't share
a. Perception of Self because sometime he just
too busy doing his job at
b. Coping Mechanism the farm and when The client stated that he is
arriving at home he will too tired to take care of
c. Support System rest, himself that he want to go Not taken can't assisted
his coping mechanism back to what it was before. because patient is not in
d. Mood / Affect Was his The Patient claimed that he a mood to
family especially his gets anxious when his family communicate.
children, his wife and and friends visit him. He just
children served as his want to get better quickly
support system. When he
is tired he became moody
but he is always smile to
others.
5. Neuro – sensory He is oriented to the time During assessment he
The client has a good people, place and most of feel pain and state
a. Mental State mental state and he has the time response of the that he doesn’t feel
b. Condition of 5 Senses: a good condition of 5 stimuli verbally physically or good, he has a good
(sight, hearing, smell, senses he can heard, over environmentally. He condition of 5 senses
taste, touch) smell, taste and feel the has a good condition of 5 he can heard, smell,
touch. senses he can heard, smell, and taste and feel the
and taste and feel the touch.
 touch.

6. Oxygenated and Vital Signs

RR:20cpm RR: 18cpm
a. Respiratory Rate PR: 63bpm PR: 61bpm
b. Pulse Rate N/A T: 36.’C T: 36.3 ‘C
c. Temperature BP: 110/ 70 mmHg BP;100/70 mmHg
d. Blood Pressure Lung sound is in normal. Lung sound is in
e. Lung Sounds He has no respiratory normal.
f. History of Respiratory Problems problems. He has no respiratory
problems.

7. Pain Comfort
The client only feel body
weakness and he only sleep
a. Pain (location, onset, intensity, duration, associated for him to rest and feel relief Patient felt cold, take a
symptoms, aggravation) He takes Paracetamol paracetamol to lessen it.
b. Comfort Measures / Alleviation N/A because he feel hot and
c. Medication cold

8. Hygiene & Activities of Daily Living
According to the client According to the client, during
he bath 2x a day, during his hospitalization he have
morning before going to not yet taking a bath
school he takes a bath because he doesn’t feel
and then when he comfortable in the rest room,
came home from school his activities was minimize
he will then takes a because of his body
bath, his activities of weakness, he is just lying in
daily living was studying his bed and also need
and playing. assistant every time he is
standing up.
According to the client,
during his
hospitalization he have
not yet taking a bath
because he doesn’t feel
comfortable in the rest
room, his activities was
minimize because of his
body weakness, he is
just lying in his bed and
also need assistant
every time he is
standing up.
 DRUG STUDY
Prescribed,
Generic Name Recommended,
Brand Name Dosage, Frequency, Mechanism of Indications Contraindications Adverse Effect Nursing Responsibilities
Classification & Route of Action
Administration
Generic Name: Prescribed: Temporary Antipyretic: Reduces Contraindicated with CNS: Headache  Administer paracetamol to
Paracetamol Dosage: 300mg reduction of fever fever by acting directly allergy to CV: Chest pain, patients as prescribed by
Acetaminophen Route: IVTT temporary relief of on the hypothalamic acetaminophen. dyspnea, healthcare providers,
Frequency: Q4 as minor aches and heat regulating center myocardial damage ensuring the correct dosage,
Brand Name: needed x fever pains caused by to cause vasodilation Use cautiously with when doses of 5–8 route, and timing of
Tylenol Recommended, common cold and and sweating, which impaired hepatic g/day are ingested administration.
dosage frequency, influenza, helps dissipate function, chronic daily for several  Assess the severity and
Classification: and route of headache, sore heat. alcoholism, pregnancy, weeks or when nature of pain or fever
Analgesics Administration: throat, toothache, lactation doses of 4g/day are before administering
(nonopioid)  For fever and backache, ingested for 1 yr. paracetamol.
Antipyretic for pain menstrual cramps, GI: Hepatic toxicity  Monitor the patient's vital
etc. and failure, jaundice signs and symptoms to
 Oral or determine the appropriate
suppository GU: Acute kidney dosage.
 500mg/tablet failure, renal tubular  Assess patients for pain
 Children and necrosis levels, fever, or discomfort
adolescents Hypersensitivity: before and after
(<60kg): Rash, fever administering paracetamol.
 Every 4-6 hrs do  Educate patients and
not exceed to caregivers about the proper
75mg/kg/day. use of paracetamol,
 For 12 years and
including the dosage,
frequency, and potential side
Frequency: effects.
Q4 PRN  Emphasize the importance
Route: of adhering to the prescribed
Oral or rectal dosage to avoid overdose.
 Monitor for signs of overdose
 or adverse reactions such as
nausea, vomiting, abdominal
pain, or jaundice.
 Accurate documentation of
paracetamol administration,
patient response, and any
observed side effects or
adverse events.
 Ensure that patients receive
the correct dosage of
paracetamol, adhere to
safety protocols, and assess
for any potential interactions
with other medications the
patient may be taking.
 Provide information about
the safe storage of
paracetamol at home to
prevent accidental ingestion,
especially in households with
children.
. DRUG STUDY
Prescribed,
Generic Name Recommended,
Brand Name Dosage, Frequency, Mechanism of Indications Contraindications Adverse Effect Nursing Responsibilities
Classification & Route of Action
Administration
Generic Name: Dosage: Increases protection  Dietary  Use of sodium  Nausea  Administer vitamin C and
Ascorbic acid 100mg/5ml, 5ml mechanism of the supplement ascorbate in  Vomiting zinc supplements to patients
Frequency: OD immune system,  Frank and patients on sodium  Heartburn as directed by healthcare
Brand Name: Route: PO thus supporting subclinical restriction;  Diarrhea providers, ensuring the
Vital C wound healing. scurvy;  Use of calcium  Headache correct dosage and proper
extensive burns, ascorbate on administration methods.
Classification: delayed fracture patient receiving  Assess patients for signs of
Vitamins or wound digitalis. vitamin C or zinc
healing, severe deficiencies, considering
febrile or chronic symptoms such as slow
disease states; wound healing, fatigue,
 To prevent weakened immune
vitamin C in response, or other relevant
patients with indications for
poor nutritional supplementation.
habits  Provide information to
 To acidify urine patients about the benefits
 Macular and potential risks
degeneration associated with vitamin C
and zinc supplementation.
 Educate patients on the
importance of a balanced
diet and how supplements
can complement nutritional
needs but are not
substitutes for a healthy diet.
 Monitor patients for
symptoms of overdose, such
as gastrointestinal upset,
 nausea, or potential
interactions with other
medications.
 Assess the patient's dietary
intake, lifestyle factors, and
health conditions that may
warrant vitamin C or zinc
supplementation.
 Collaborate with the
healthcare team to
determine appropriate
dosages based on individual
needs.
 Maintain accurate records of
vitamin C and zinc
supplementation, including
dosage, frequency, patient
responses, and any observed
side effects or adverse
events.
 Ensure patients receive
appropriate guidance on the
correct dosage and timing of
vitamin C and zinc
supplements, adhering to
safety protocols and
guidelines.
 Collaborate with healthcare
providers to monitor the
patient's response to
supplementation.
 Prescribed,
Generic Name Recommended,
Dosage, Frequency,
Brand Name & Route of Mechanism of Indications Contraindications Adverse Effect Nursing Responsibilities
Administration Action
Classification

Generic Name: Dosage: Omeprazole is a This medicine Diarrhea from Back, leg, or Administer Omeprazole to
Omeprazole 40 mg selective and contains an infection stomach patients as prescribed by the
irreversible proton omeprazole which with Clostridium pain healthcare provider, ensuring
pump inhibitor. It works by difficile bacteria. Bleeding or the correct dosage and route of
suppresses decreasing the Inadequate crushing administration.
Brand Name: Frequency: stomach acid amount of acid
secretion by specific produced in the vitamin B12. sores on the Gather information about the
Omepron Once a day inhibition of the stomach. lips patient's medical history,
Low amount of including any history of
H /K -ATPase
+ + Omeprazole is used magnesium in Blisters. gastrointestinal issues, allergies,
system found at for the short-term the blood. or medications that might
Classification: Route: the secretory treatment and Continuing
surface of gastric symptomatic relief Liver problems ulcers or interact with Omeprazole.
Proton pump IVTT parietal cells. of heartburn that sores in the
inhibitors (PPIs) A type of kidney mouth Assess patients for indications,
occurs two or more inflammation contraindications, and any
days per week called interstitial Difficult, potential adverse effects or
(frequent nephritis burning, or allergies related to Omeprazole.
heartburn). painful
Subacute urination Educate patients about
cutaneous lupus Omeprazole, including its
erythematosus. General purpose, dosage, potential side
feeling of effects, and proper
Systemic lupus discomfort administration.
erythematosus or illness. Provide information on lifestyle
An autoimmune Itching, skin modifications that complement
disease rash the medication.
Muscle Monitor patients for any side
aches or effects or adverse reactions
cramps after administering Omeprazole.
Keep track of vital signs, assess
for signs of improvement or
worsening of symptoms, and
report any concerns to the
healthcare team.
Accurate documentation of
medication administration,
patient response, and any
observed side effects or adverse
events.
Ensure that patients receive the
right medication at the correct
dose and time, following safety
protocols and adhering to
medication administration
guidelines.
Provide counseling on the
importance of adhering to the
prescribed dosage and
schedule, emphasizing the need
to complete the full course of
medication even if symptoms
improve.
 Prescribed,
Recommended,
Generic Name Dosage, Frequency,
Brand Name & Route of Mechanism of Indications Contraindications Adverse Effect Nursing Responsibilities
Administration Action
Classification

Generic Name: Prescribed: Temporary Antipyretic: Reduces Contraindicated with CNS: Headache Administer paracetamol to
Dosage: 300mg reduction of fever fever by acting directly allergy to CV: Chest pain, patients as prescribed by
Paracetamol temporary relief of on the hypothalamic acetaminophen. healthcare providers, ensuring
minor aches and heat regulating center dyspnea, the correct dosage, route, and
Acetaminophen Route: IVTT pains caused by to cause vasodilation myocardial damage timing of administration.
Frequency: Q4 as common cold and and sweating, which Use cautiously with when doses of 5–8
needed x fever influenza, helps dissipate impaired hepatic g/day are ingested Assess the severity and nature
Brand Name:
Recommended, headache, sore
throat, toothache,
heat. function, chronic daily
weeks
for several
or when of pain or fever before
Tylenol dosage frequency, alcoholism, pregnancy, doses of 4g/day are administering paracetamol.
and route of backache, lactation ingested for 1 yr.
menstrual cramps, Monitor the patient's vital signs
Administration: etc. GI: Hepatic toxicity and symptoms to determine the
Classification: For fever and and failure, appropriate dosage.
Analgesics for pain jaundice Assess patients for pain levels,
(nonopioid) Oral or GU: Acute kidney fever, or discomfort before and
Antipyretic suppository failure, renal tubular after administering
necrosis paracetamol.
500mg/tablet
Hypersensitivity: Educate patients and caregivers
Children and Rash, fever about the proper use of
adolescents paracetamol, including the
(<60kg): dosage, frequency, and
Every 4-6 hrs potential side effects.
do not Emphasize the importance of
 exceed to adhering to the prescribed
75mg/kg/day. dosage to avoid overdose.
For 12 years Monitor for signs of overdose or
and adverse reactions such as
Frequency: nausea, vomiting, abdominal
pain, or jaundice.
Q4 PRN
Accurate documentation of
Route: paracetamol administration,
Oral or rectal patient response, and any
observed side effects or adverse
events.
Ensure that patients receive the
correct dosage of paracetamol,
adhere to safety protocols, and
assess for any potential
interactions with other
medications the patient may be
taking.
Provide information about the
safe storage of paracetamol at
home to prevent accidental
ingestion, especially in
households with children.
 Prescribed,
Generic Name Recommended,
Dosage,
Brand Name Frequency, & Mechanism of Indications Contraindications Adverse Effect Nursing Responsibilities
Route of Action
Classification Administration

Generic Name: Prescribed: Inhibits the action Short-term Hypersensitivity to the Confusion Administer ranitidine as
Ranitidine Dosage: 50 mg of histamine at the treatment of active drug or any of the Dizziness prescribed by healthcare
H2-receptor site duodenal ulcers ingredients, providers, ensuring accurate
Frequency: Q8 located primarily in and benign gastric Drowsiness dosage, correct route, and
gastric parietal ulcers proper timing of administration.
Brand Name: Route: IVTT cells, resulting in Hallucinations
inhibition of gastric Assess patients for symptoms
Zantac acid secretion. Headache related to excessive stomach
Arrythmias acid, such as heartburn,
indigestion, or abdominal
Classification: discomfort, before and after
administering ranitidine.
Antiulcer
Monitor the effectiveness of
the medication in alleviating
symptoms.
Educate patients about
ranitidine, explaining its
purpose, dosage regimen,
potential side effects, and the
importance of adherence to
the prescribed treatment plan.
Monitor patients for signs of
headache, dizziness, diarrhea,
or rare but serious adverse
reactions like liver problems
and report any concerns to the
healthcare team.
Review the patient's medical
history for conditions such as
kidney or liver disease, allergies,
or any medications that might
interact with ranitidine.
Accurate documentation of
ranitidine administration,
patient response, and any
observed side effects or
adverse event.
Collaborate with healthcare
providers to assess the
patient's response to ranitidine,
communicate any changes in
the patient's condition, and
ensure appropriate
adjustments to the treatment
plan.
Provide guidance on lifestyle
modifications such as dietary
changes or alterations in
eating habits to complement
the effects of ranitidine in
managing stomach acid-
related conditions.
Calculate the appropriate
dosage of ranitidine based on
the patient's condition, age,
weight, and severity of
symptoms.
 NURSING CARE PLAN

CUES NURSING OBJECTIVES INTERVENTIONS EVALUATION

DIAGNOSIS
Subjective: Hyperthemia Within my 8  Establish rapport After 8 hours of duty,
“Dadn ah bag’r akn” as verbalized related to hours of shift, the Instructed pt to increase fluid intake patient body
by the patient increased patient body  temperature will be
metabolic rate, temperature will  Administer medication as Dr. order. lowered from 38.2 to 37.1
Objective: illness. be lowered from
 Body weakness noted 38.1 to 37.1  Monitored V/S BP: 100/70 mmHg
Instructed S/O to perform TSB to the pt T: 37.1 C
 With facial grimace 
PR: 60 BPM
 Restlessness
 Encourage S.O to promote good ventilation RR: 18 CPM
 Flushed skin noted  Instructed S.O to promote comfortable and O2sat: 96%
 Dry skin noted
 Dry mouth noted
light clothing
 Irritability  Promote therapeutic environment
 Headache
 Dizziness
 Monitor intake and output
BP: 110/70mmHg  Maintain bed rest
T: 38.1 Provide high calorie deficit
PR: 64 BPM 
RR: 20 CPM  Assess underlying condition/diseases that
O2sat: 96%
might be a contributing factors.
ANATOMY AND PHYSIOLOGY
(IDEAL)
 Non- modifiable Modifiable
Male PATHOPHYSIOLOGY Smoking
23 yr old (Actual)
mode of entry of dengue virus
through an aedes aegypti
mosquito bites
Nursing Interventions Nursing Management
•Monitor Vital Signs Inoculation of virus at thr bloodstream and •Increased body
dissemination to the blood cells temperature related to
•Fluid replacement. infection as evidence by
Establish 24hr fluid Inflammatory response intiated (WBC) vital sign monitoring.
replacement needs
•Oral rehydration therapy
•Manage nose bleed— Production of B-lymphocytes and secretion of
elevate position and apply immunoglobutings (antibodies) monocytes, •fluid volume deficit related
ice bag microphages neutrophils to migration of intravascular
fluid into extravascular fluid.
•Continuous Monitoring of Antibodies attach to viral antigens, and action of
blood test results — inform •Impaired nutrition less than
doctor immediately for signs phagocytosis by monocytes body requirement related to
of impending shock decreased appetite
Dengue virus replicates on the cells of monocytes and
•Continuous monitoring of eventual recognition of dengue viral antigen in
intake output chart infected monocytes by cytosis T-cells
—encourage pt. to drink
Release of cytokines containing vasoactive agents like Signs and symptoms
interleukins and platelet activating factors which Fever
stimulates WBC's and pyrogen release Chill
Body Weakness
DENGUE FEVER Headache
ANATOMY
 HEALTH EDUCATION

what is dengue fever?

-Dengue fever - is a painful, debilitating mosquito-borne disease Caused by any one of four closely related dengue viruses.
How is dengue fever acquired?
Dengue Fever is transmitted by the bite of an aedes mosquito Infected with a denque vinus.
What are the symtomi of Derque Fever?
Symptions, which usually begin four to fix daull after infection and last for us to locdays, may include
• Sudden high fever
Pain behind the eyes.
• Severe headache
haisea
Vomiting
Skin rash
How can Dengue fever be prevented?
• Mild breeding
Stay away from heavily populated residental areas, If possible. • when Outdoor, wear long-Sleeved Shirts and long pants fucked
into Suck
• Make sure window and door (creens are Secure and Free Of holes)