Christ the King College Nursing Program Gingoog City

Dengue (break-bone fever)

A Case Study on the Concept of Infectious Diseases: In partial fulfillment for the midterm requirement of NCM 107 (Related Learning Experience)

Submitted to Mrs. Emily C. Albacete, RN Clinical Instructor

Submitted by Leilani Rodriguez-Ampo Bachelor of Science in Nursing IV

Date January 27, 2012

Table of Content
I. Objectives & Introduction

II. Personal Information Data III. Developmental Data IV.Assessment V. Anatomy and Physiology VI.Pathophysiology VII.Nursing Care Plans VIII.Drug Analysis/Study IX.Discharge Planning X. Diet Analysis XI.Prognosis XII.Evaluation XIII.Recommendation XIV.References XV.Appendices

General Objective
This case presentation aims to identify and determine the general health problems and needs of the patient with an admitting diagnosis of Systemic Viral Illness R/I Dengue Fever. This presentation also intends to help patient promote health and medical understanding of such condition through the application of the nursing skills.

Specific Objectives
To raise the level of awareness of patient on health problems that he may encounter.

To facilitate patient in taking necessary actions, to solve and prevent the identified problems on his own.

To help patient in motivating him to continue the health care provided by the health workers.

To render nursing care and information to patient through the application of nursing skills.

Dengue fever is an infectious disease carried by mosquitoes and caused by any of four related dengue viruses. This disease used to be called break-bone fever because it sometimes causes severe joint and muscle pain that feels like bones are breaking, hence the name. Health experts have known about dengue fever for more than 200 years.

Introduction
This epidemic disease, which occurs in tropical areas, is caused by a virus that is usually transmitted by a mosquito (aedes aegypti). It is rarely seen in the United States. After an incubation period of five to seven days, symptoms appear suddenly with high fever up to 106*F (41*C), flushed face, headache, painful eyeballs, sorethroat, nervousness, disturbed sleep, and severe pain in the head, back, and joints (hence the term breakbone). Prostration may be great. About the third or fourth day the temperature usually drops to normal, only to recur after about three days. The second wave of illness is usually less severe and shorter in duration, and is accompanied with a rash on the hands and feet that spreads to arms, legs, and body. The acute symptoms soon end. Usually the disease is self-limited, but convalescence is slow. There is no specific treatment, and deaths from the disease are almost unknown. Good nursing is important. Bed rest and drinking an abundance of water are essential. Cool enemas and tepid baths will lower the temperature should it rise above 104*F (40*C). An ice bag to the head usually feels good.

Personal Information Data

Name: Charlemagne B. Dime Age: 14 years old Sex: Male Child Nationality: Filipino Religion: Roman Catholic Parents: Mr. and Mrs. Gregorio Dime Address: Purok 3 North Poblacion, Medina, Misamis Oriental Date admitted: January 01, 2012 Time admitted: 10:15 AM Chief complaints: Fever x 2 Days Admission Impressions: Systemic Viral Illness R/I Dengue Fever Attending Physician: Dr. Harold R. Cagang Vital signs: Temperature: 38.8 C Heart Rate: 90 bpm Respiration Rate: 24 cpm Weight: 57 kgs.

Developmental Data
Freuds Psychosexual Stage : Genital stage: Adolescent

develops sexual maturity and learns to establish satisfactory relationships with the opposite sex.

Nursing Implications: The client said he is a typical teenager who loves to explore opposite sex relationship, fond of going out after school and have fun at the recreational areas with friends of the same age.

Eriksons Developmental Task: Erikson believed the new interpersonal dimension that emerges during adolescence is a sense of identity versus role confusion. Nursing Implication: According to the client he is well provided with love and care by his parents. He is being supported and praised for any decision making he does or any feelings he discussed about events important to him which makes him sure of himself as a person.

Piagets

Cognitive

Development:

Piaget

saw

adolescence as the time when cognition achieves its final form, that of formal operational thought. Nursing Implication: The client expresses worry of his illness because he is aware of the possibility of fatality with this disease if left untreated and unattended.

Assessment Family History:

Client was born second to the oldest among three siblings. The family has no health problems, except the mother is currently being monitored with her

Hypertension which is induced due to her fourth pregnancy. However, Charlemagne is the first in the family being brought to hospital for such illness.

Disease History:
One day prior to his admission, the client said he was gallivanting at the neighbors place last December 31, 2011 (Saturday), and was caught by the rain. When he reached home he was having chills and hyperthermia. His parents decided to bring him to hospital since he was vomitus and having chills and fever.

Physical Assessment Tool:

Neurologic System The patient was lethargic during admission as observed by NOD.

Digestive System The abdomen was not distended, soft and there was no palpable mass upon palpation. Hyperactive bowel sound heard upon auscultation. The patient vomited once prior to admission. Respiratory system His respiratory pattern is not in regular range for his age as evidenced by his respiratory rate of 25 cpm. His breath is having tachypnea because it is faster than 20 breaths per minute. Cardiovascular system

His apical pulse is 90 bpm and his radial pulse is 88 bpm. His heart sounds are normal. There are no murmurs heard in the apical pulse upon inhalation and exhalation. Musculoskeletal System The patient manifested good posture and moved voluntarily; he had symmetrical musculature on both sides of the body. Weakness was noted and client is complaining of muscle pains and joint pains. Genito-Urinary System Patient voided 60-250 cc per shift as monitored through I&O, and yellow in color as verbalized by the client. Integumentary System Thick and curly distributed hair was noted. His nails were convex shape, smooth in texture, capillary refill of 2 seconds of an untrimmed finger nails with sweaty palms. His skin was flushy red, warm to touch and fare complexion. HEENT The size of the head was in proportion with the body. The eyes were symmetrical with ears; with painful red eyes (Conjunctival suffusion). When the eyes were tested papillary reaction to light, the pupil constricted to 2mm. Ear had no discharges noted. Patients throat was functioning well and in normal condition.

Activity The patient can move his extremities but with joint pains and muscle pains. He can move and walk without assistance and was given comfort room 8

privileges. He misses watching TV as his only means of recreation at home. He is bored in the hospital confinement.

Sleep and rest He usually sleeps at 8:00 pm and rise at 6:00 am. Sometimes his sleeping pattern is only disturbed when he is not feeling well. The patient feels different about himself since his hospitalization because of many restrictions imposed by the health care team plus the uncomfortable condition of the IV fluids attached to his arm and the muscle and joint pains that is disturbing his comfort to sleep.

Values and Beliefs The clients family goes to Catholic church every Sunday and believes in every celebration of Christmas Eve, New Years Day, Lenten season and Easter Sunday.

Physical Examination Vital sign DATE 1-01-12 Temperature Pulse rate 38.8C 90bpm 38.7C 98bpm 38.2C 100bpm 9 7-3 3-11 11-7

Respiratory rate

24cpm

25cpm

22cpm

A. Skin- warm, flushed red, fair in complexion, with sweaty palms B. Nails- pallor nail bed, dirty with fine capillary refill (approximately within 2 seconds) C. Head/ face -no mass palpated, flushed face D. Scalp- thick curly hair evenly distributed with no dandruff or lesions observed E. Eyes- with red sore conjunctival suffusion, no discharges noted, pupils are equally round and reactive to light and accommodation F. Ears- symmetrical with cerumen, no discharges noted G. Nose-no flaring of nostrils, no discharges noted H. Mouth-dry mucous membranes and pale lips I. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and pain J. Chest and Lungs- without crackles and ronchi K. Abdomen- soft, not distended L. Extremities- weak extremities, muscle and joint pains M. GIT- loss of appetite N. Renal and Urologic changes-decrease urine output(<30ml/hr) O. Cardiovascular changes- none P. Hematopoietic changes none Vital sign DATE 1-02-12 Temperature Pulse rate Respiratory rate 37.8 C 37.2C 38.1 C 7-3 3-11 11-7

100bpm 110bpm 92bpm 29cpm 30cpm 24cpm

A. Skin- warm, flushed red, fair in complexion, with sweaty palms B. Nails- pallor nail bed, dirty with fine capillary refill (approximately within 2 seconds) C. Head/ face -no mass palpated, flushed face 10

D. Scalp- thick curly hair evenly distributed with no dandruff or lesions observed E. Eyes- with red sore conjunctiva suffusion, no discharges noted, pupils are equally round and reactive to light and accommodation F. Ears- symmetrical with cerumen, no discharges noted G. Nose-no flaring of nostrils, no discharges noted H. Mouth-dry mucous membranes and pale lips I. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and pain J. Chest and Lungs- without crackles and ronchi K. Abdomen- soft, not distended L. Extremities- weak extremities, muscle and joint pains M. GIT- loss of appetite N. Renal and Urologic changes-decrease urine output(<30ml/hr) O. Cardiovascular changes- none P. Hematopoietic changes none

Diagnostic and Laboratory Results

Date: January 01, 2012 Complete Blood Count Result

Time: 10am

Normal Value

White Blood Cell Hemoglobin

5,900 14.4

4.5 11.0 X 10/mm Fem- 11.7 14.5 g/dl Male-13.7- 16.7 g/dl

Hematocrit

42.0

Fem-34.1-44.3 vol % Male-39.3-48.0 vol %

Platelet Segmenters

115,000 86

175,000-350,000/mm 45-70%

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Lymphocytes Monocytes

11 03

18-45% 3-8%

Interpretation:
Platelets is lower than normal range which would risk for bleeding tendency and coagulation problems or hemolysis. Lymphocytes is lower than normal range which might need help in fighting against infection. Indicates decrease immune system. Segmenters indicates high glucose level in the blood.

Diagnostic and Laboratory Results

Date: January 02, 2012 Complete Blood Count Result

White Blood Cell Hemoglobin 3,200 15.9

Time: 10am

Normal Value
4.5 11.0 X 10/mm Fem- 11.7 14.5 g/dl Male-13.7- 16.7 g/dl

Hematocrit

47.9

Fem-34.1-44.3 vol % Male-39.3-48.0 vol %

Platelet Segmenters Lymphocytes

106,000 84 14

175,000-350,000/mm 45-70% 18-45%

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Monocytes

02

3-8%

Interpretation:
Platelets rapidly drops more lower than normal range which would risk for bleeding tendency and coagulation problems or hemolysis. Lymphocytes is lower than normal range which might need help in fighting against infection. . Indicates decrease immune system Segmenters indicates high glucose level in the blood. WBC a decrease value indicates inadequate inflammatory defenses to suppress I. Anatomy and Physiology of the Blood infection and humoral immunity takes place. ANATOMY AND PHYSIOLOGY

The Immune System A second line of defense is housed within the body: a finely tuned immune system that recognizes and destroys foreign substances and organisms that enter the body. The immune system can distinguish between the body's own tissues and called outside substances

antigens. This allows cells of the immune army to identify and destroy only those enemy antigens. The ability to identify an antigen also permits the immune system to "remember" antigens 13

the body has been exposed to in the past; so that the body can mount a better and faster immune response the next time any of these antigens appear. The immune system also includes other proteins and chemicals that assist antibodies and T cells in their work. Among them are chemicals that alert phagocytes to the site of the infection. The complement system, a group of proteins that normally float freely in the blood, move toward infections, where they combine to help destroy microorganisms and foreign particles. They do this by changing the surface of bacteria or other microorganisms, causing them to die. Enzyme (EN-zime) is a protein that helps speed up a chemical reaction In the body. Antigens (AN-tih-jens) are substances that are recognized as a threat by the body's immune system, which triggers the formation of specific antibodies against the substance. Bone marrow is the soft tissue inside bones where blood cells are made. Lymphatic (lim-FAH-tik) system is a system that contains lymph nodes and a network of channels that carry fluid and cells of the immune system through the body. Immunity (ih-MYOON-uh-tee) is the condition of being protected against an infectious disease. Immunity often develops after a germ is introduced to the body. One type of immunity occurs when the body makes special protein molecules called antibodies to fight the disease-causing germ. The next time that germ enters the body, the antibodies quickly attack it, usually preventing the germ from causing disease. Primarily, the immune system classifies a substance as: a. Self-non-foreign they are normally ignored and tolerance and is exhibited towards these substances. They are not deemed harmful. b. Non-self termed as an antigen; a specific response is developed to a specific antigen. The response is then stored in the immune systems memory cells for future reference. Components of the Immune System: 14

1. Lymphoid Structures Spleen Composed of red and white pulp, acts somewhat like a filter. The red pulp is the site where old and injured red blood cells are destroyed. The white pulp contains concentrations of lymphocytes. Are distributed throughout the body Are connected by lymph channels and capillaries, which remove foreign material from the lymph before it enters the bloodstream. 1. Immune Cells Lymphocytes a. B lymphocytes (or B cells) - produce immunoglobulins. b. T lymphocytes (or T cells) - help control the immune response and destroy foreign antigens directly. c. Plasma Cells - are white blood cells that produce large volumes of antibodies. 1. Tissues The remaining lymphoid tissues, such as the tonsils and adenoids and other. Mucoid Lymphatic Tissue contain immune cells that defend the bodys mucosal surfaces against microorganisms. Types of Immune Defense: a. Innate or Nonspecific Immunity Also termed as the persons natural resistance, and are the most basic and primary of all defenses in the body. membranes, phagocytic activity) 1. Immune Cells Lymphocytes a. B lymphocytes (or B cells) - produce immunoglobulins. b. T lymphocytes (or T cells) - help control the immune response and destroy foreign antigens directly. 15 (skin, mucus Lymph Nodes

c. Plasma Cells - are white blood cells that produce large volumes of antibodies. 1. Tissues The remaining lymphoid tissues, such as the tonsils and adenoids and other. Mucoid Lymphatic Tissue contain immune cells that defend the bodys mucosal surfaces against microorganisms. 2 Types of Immunity Active acquired through previous exposure of the disease or through immunization wherein the body actively participates in formation of antibodies for future reference. Passive refers to whole, ready made immunity acquired from another, the body is just passive in the process of developing antibodies, as it is already made and given readily. 4 Types of Active Immunity a. Humoral Immunity b. Mucosal Immunity c. Cell-mediated Immunity d. Delayed HypersensitivityReaction Antibodies or Immunoglobulins developed from B-cells through the stimulation of cytokines produced by helper T-cells in the presence of an antigen. They attach to specific determinant sites on antigens, and carries out phagocytosis and initiating inflammation. IgG 75% Crosses placental barrier; present in circulation and tissue spaces; antiviral, antitoxic and anti-bacterial properties; IgA 15% activates complement Found in body secretions and breast milk; protects mucous 16

IgM IgE IgD

10% .2% .004%

membranes from microorganisms Forms natural ABO antibodies; present in early immune responses; activates complement Hypersensitivity reaction mediator; Involved in parasitic infectious Necessary for maturation of B lymphocytes

Hematologic System Two types of blood vessels carry blood throughout our bodies: 1. Arteries carry oxygenated blood (blood that has received oxygen from the lungs) from the heart to the rest of the body. 2. Blood then travels through veins back to the heart and lungs, where it receives more oxygen. The blood that flows through this network of veins and arteries is whole blood, which contains three types of blood cells: 1. Red blood cells (RBCs) (also called erythrocytes) are shaped like slightly indented, flattened disks. RBCs contain the iron-rich protein hemoglobin. Blood gets its bright red color when hemoglobin picks up oxygen in the lungs. As the blood travels through the body, the hemoglobin releases oxygen to the tissues. The body contains more RBCs than any other type of cell, and each has a life span of about 4 months. Each day, the body produces new RBCs to replace those that die or are lost from the body. 1. White blood cells (WBCs) (also called leukocytes) are a key part of the body's system for defending itself against infection. They can move in and out of the bloodstream to reach affected tissues. Blood contains far fewer WBCs than red blood cells, although the body can increase WBC production 17

to fight infection. There are several types of WBCs, and their life spans vary from a few days to months. New cells are constantly being formed in the bone marrow. Certain types of WBCs produce antibodies, special proteins that recognize foreign materials and help the body destroy or neutralize them. The white cell count (the number of cells in a given amount of blood) in someone with an infection often is higher than usual because more WBCs are being produced or are entering the bloodstream to battle the infection. 1. Platelets (also called thrombocytes) are tiny oval-shaped cells made in the bone marrow. They help in the clotting process. When a blood vessel breaks, platelets gather in the area and help seal off the leak. Platelets survive only about 9 days in the bloodstream and are constantly being replaced by new cells. Platelets and clotting factors work together to form solid lumps to seal leaks, wounds, cuts, and scratches and to prevent bleeding inside and on the surfaces of our bodies. The process of clotting is like a puzzle with interlocking parts. When the last part is in place, the clot happens but if even one piece is missing, the final pieces can't come together.

Pathophysiology of Dengue Fever

18

Predisposing
Geographical area-Tropical islands In the Philippines (Asia Pacific)

Precipitating
Environmental conditions Immuno-compromise Mosquito carrying dengue virus Soldier, Students Sweaty skin

Aedes Aegypti (dengue virus carrier) 8-12 days of viral replication on mosquitoes salivary glands. Bite from mosquito (portal entry in the skin) Redness & itchiness

Allowing dengue virus to be inoculated towards the circulation/blood (Incubation Period: 3-14 days)
Virus disseminated rapidly into the blood and stimulates WBCs including B-lymphocytes that produces and secretes immunoglobulins (antibodies), and monocytes, macrophages, neutrophils Diagnostic Hematology: WBC 12,900/cumm (5,000-10,000)

Lymphocytes 49% (20-40%)

Antibodies attach to the viral antigens, and then monocytes/macrophages perform phagocytosis through Fc receptor w/in the cells and dengue virus replicates in the cells.

Entry to Spleen
Diagnostic hem: Monocytes:42%

Neutrophils 49% Entry to Bone

Recognition of dengue antigen on infected monocyte

Release of cytokines w/c consist of vasoactive agents such as interleukins, tumor necrosis factor, urokinase and platelet activating factors w/c stimulates WBCs and pyrogen release Signs/Symptoms :

Febrile:38.6*C
Diaphoresis,warm skin, flushed, Headache of 3/10 pain scale

Dengue

Narrative Pathophysiology of Dengue Fever

19

Dengue fever is a severe potentially deadly infection spread by Aedes Aegypti mosquitoes through salivary glands that enters human skin portals (biten). Dengue virus inoculates in blood circulation and incubates within 3-14 days. Virus disseminated rapidly into the blood and stimulates WBCs including Blymphocytes that produces and secretes immunoglobulins (antibodies),

monocytes, macrophages, and neutrophils. At this stage, there will be an increase of WBCs and Lymphocytes. Antibodies attach to the viral antigens, and then monocytes/macrophages perform phagocytosis through Fc receptor within the cells and dengue virus replicates in the cells. Replicated virus cells will then enter the Spleen and Bone Marrow. Within this period the monocytes and neutrophils will decrease. Dengue viral antigen will be recognized on the infected monocyte. Release of cytokines will stimulate WBCs and the release of pyrogens A manifestation of hyperthermia, diaphoresis, warm skin, flushed face, and headache is usually shown. Virus attacks liver and spleen and causes cell death and other complications such as intense bleeding, pulmonary edema, shock, liver cirrhosis or death.

20

NURSING CARE PLAN Nursing Diagnosis: Hyperthermia related to illness, exposure to viral/bacterial environment. Cause Analysis: Pyrexia is common if inflammation is extensive. If fever infection has caused inflammation, fever can be severe depending on particular microorganism. Fever results from the release of pyrogens. NURSING CUES OBJECTIVES RATIONALE EVALUATION INTERVENTIONS Subjective: LTO: Independent: After series of Gi takigan ko, ug intervention the taas ako hilanat, nag At the end of 2 days 1. Identification patient: sakit ako ulo gikan intervention the patient 1. Determine and gahapon, as will be able: precipitating management of Was not yet verbalized by the factors. underlying relieved of patient. to recover from cause are fever decreasing essential to thoroughly. platelet count. 2. Assess vital signs recovery. Platelets Objective: STO: especially 2. To provide rapidly Flushed skin tympanic or rectal accurate core decreases Fever: 38.8*C At the end of 8 hours temps. temperature. and patient Diaphoresis intervention the 3. to decrease was Red Eyes patient will be able to: 3. Provide fluids by transferred warmth and Inc. Resp. Rate mouth. for a tertiary increases Chills Maintain body care.But evaporative Headache temperature 4. Provide cold patient is cooling. Dec. platelet count below 37.8*C packs and tepid relieved w/ 4. to promote sponge bath. fever after cooling & immediate lowering temp. interventions given.

21

Collaborative: 1. Provide antipyretic medications PRN

-Goals are met partially1.To prevent cellular damage, delirium, and convulsions.

NURSING CARE PLAN Nursing Diagnosis:

22

Acute Pain related to biological factors such as activity of disease process. Cause Analysis: Fever infection has caused inflammation, fever can be severe depending on particular microorganism. Fever results from the release of pyrogens. And causes cell destruction, pain in the body parts and other complications. CUES OBJECTIVES NURSING RATIONALE EVALUATION INTERVENTIONS Subjective: LTO: Independent: After series of Sakit kayo ulo,ako intervention the mata, mga bukog ug At the end of 3 days 1. Assess pain noting 1.To provide patient: muscles, verbalized intervention the patient location, duration, information and by the client. will be able: intensity. determine Was not yet interventions. relieved of Objective: to recover from on and off 3 Flushed skin muscle and joint 2. Encourage 2.To flush days fever. Fever: 38.8*C pains. increase fluid bacteria and Platelets Diaphoresis STO: intake. toxins and rapidly Red Eyes regulate body decreases Inc. Resp. Rate At the end of 8 hours 3. Provide comfort temperature. and patient Chills intervention the 3.To provide was measure such as Headache patient will be able to: relaxation and transferred use of heat/cold Dec. platelet count refocuses for a tertiary packs, Body malaise verbalize attention from care.Howeve repositioning, quiet Joint pains adequate relief pain and r patient is environment . Muscle pains of pain or ability enhance coping relieved w/ to cope with mechanism. headache 4. Investigate results incompletely 4. indication of through cold of platelet count. relieved pain in Dengue fever packs. the muscle & infection at risk. joints& head. -Goals are met Collaborative: 1. Reduces pain, 1. Administer fever, and antipyretic

23

medications PRN/ antibacterials/antivi rals if prescribed.

infections that is affecting body system of the patient.

NURSING CARE PLAN Nursing Diagnosis: Imbalanced Nutrition: less than body requirements related to inability to ingest food. Cause Analysis:

24

CUES Subjective: Dili nako kaya magtulon pagkaon, busog perme ako tiyan,makasuka ko, as verbalized by the client. Objective: Anorexia Fever: 38.8*C Vomitus Chills Body malaise/weakness Fatigue

Intake of nutrients insufficient to meet metabolic needs. OBJECTIVES NURSING RATIONALE INTERVENTIONS LTO: Independent: At the end of 3 days intervention the patient will be able: to demonstrate progressive weight gain and strength. 1. Assess Causative factor for malnutrition. 2. Determine clients ability to chew, swallow, and taste food. Evaluate teeth and gums for poor oral health, note gum bleedings. 3. Prevent unpleasant odors/sights. 4. Promote pleasant relaxing environment including oral care before and after meals. Collaborative: 1. Promote adequate/ timely fluid intake. Limit fluids 1 hour 1.To determine how to meet metabolic needs of patient. 2.All factors can affect ingestion and or digestion of nutrients. 3.This may have a negative effect on appetite/eating. 4. To enhance food intake.

EVALUATION After series of intervention the patient: Was able to improved his nutrition intake by taking fruit juices and slowly taking hot soups brought to him.-Goals are met

STO: At the end of 8 hours intervention the patient will be able to: verbalize relief from Anorexia.

1. To reduce possibility of early satiety.

25

prior to meal. 2. Encourage use of lozenges.

2. To stimulate salivation when dryness is a factor.

DRUG STUDY Date Ordered: January 01, 2012 Name of Drug Classification Why Given to Contraindication Patient in Relation to the Mechanism of Side Effect Nursing Consideration

26

Generic (Brand) Apap,paracetam ol Acetaminophen Dose/Frequency Prescribed 500mg 1tab q 4 for PRN T>38.8*C. Recommended Dose and Frequency Usual starting dosage based on patient response. Maximum dose, 640 mg/day PO q 4* to 6* PRN.

Therapeutic: Nonopioid Analgesics and Antipyretics Pharmacologic: Para-aminophenol derivatives Stability of the Drug: Stored in a room temperature

Action Unknown. Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS. The drug may relieve fever through central action in the hypothalamic heat regulating center.

Hypersensitivity drugs.

to Stimulation, drowsiness, nausea, Indication vomiting, Treatment of mild abdominal pain, pain or fever. hepatotoxicity, seizure, renal failure, hemolytic anemia, CNS stimulation, delirium, vascular collapse, convulsions, coma, death.

Assess patients type of pain, location, intensity, duration, temp., diaphoresis. Assess allergic reactions: rash,urticaria Assess for chronic poisoning: rapid pulse, weak pulse, dyspnea,cold clummy skin, report immediately.

27

Discharge Planning
Medication Intake of appropriate vitamin supplement and diuretics to increase protection mechanism of the immune system and decreases renal vascular resistance and may increase renal blood flow, respectively. Economic The use of non pharmaco therapy such as drinking plenty of water will promote increase plasma in blood to increase immunity and proper hygiene and promotion of cleanliness at home and work area. Treatment Management of such condition would be through hydration and doing control measures to eliminate vector by promoting cleanliness in the environment through proper disposal of rubber tires, changing of water of lower vases once a week, destruction of breeding places of mosquito and residual spraying with insecticides. Hygiene Advise to follow proper body hygiene and to maintain cleanliness on surroundings. This would prevent additional cases of DHF. Out Patient/ Follow-up Any odd signs such as fever, petechiae, recurrence of fever, must be immediately reported to the physician. Diet Instruct to eat no dark colored foods or hemoglobin free diet that can interfere test for stools.

Diet Analysis
28

Patient having dengue fever must have to follow a normal diet or diet as tolerated to foster wasting of nutrient which the patient has loss during the sickness.

The importance of why the patient ordered to have a No dark colored food or hemoglobin free diet is to prevent interference during stool exam results.

It is safe to serve Cheese, milk, eggs, non-leafy vegetables, refined vegetables, fruits and fruit juices.

Avoid alcoholic and acidic beverages that may irritate the GIT and stimulate vomiting. Instruct patient to eat foods that are low fat, low fiber, nonirritating and non-carbonated.

Sample Diet for One Day 29

Breakfast: 6:00 7:00 Papaya Fried vegetarian tocino Boiled camote Unpolished rice Warm milk

Lunch: 11:45 12:15 Low salt boiled camote tops Unpolished rice 3 ounces sliced turkey 1 lettuce leaf 1/2 cup cucumber salad 1 medium apple

Evening Meal: 6:30 7:00 3 ounces broiled fish 1/2 cup rice 1/2 cup green beans 1 cup lettuce salad 2 teaspoons margarine 1 cup lemon water

Prognosis

30

Typical dengue is fatal in less than 1% of cases. The acute phase of the illness with fever and myalgias lasts about one to two weeks. Convalescence is accompanied by a feeling of weakness (asthenia), and full recovery often takes several weeks. The prognosis is good as long as the client complies to proper medications, proper nutrition, adequate hydration and proper hygiene. The

parents can financially support their son for a tertiary care if any complication arises.

CRITERIA FOR PROGNOSIS BASING FROM THE FOLLOWING A. Age B. Onset of Illness C. Duration of Illness D. Nature of Illness E. Support System F. Financial Support G. Compliance of Treatment Good Poor Poor Moderate Good Good Good

Evaluation

31

The patient in this study had undergone supportive and symptomatic management. He was admitted last January 01, 2012 at MOPH-Gingoog City and was eventually transferred to Cagayan de Oro City last January 03, 2012 for a tertiary care due to rapidly dropping platelets caused by Dengue Fever Virus.

Proper nursing care such as water therapy and administration of prescribed drugs were done to promote comfort and repression of symptoms. Hygiene was also strictly implemented to avoid risk for further infection. Nursing assistance was also given to help him in his activities of daily living.

Health teaching is a very important role on the part of the nurses. This is of great significance to the knowledge deficit of patients regarding health and illness.

Recommendation

32

Strict compliance to the medical treatment, health teachings and medical check-up is advised. With proper nutrition and conformity to the medications & therapy, recovery would be easier and faster.

There is no specific treatment for classic dengue fever, and like most people you will recover completely within 2 weeks. To help with recovery, health care experts recommend: Getting plenty of bed rest Drinking lots of fluids Taking medicine to reduce fever

Often health care provider advises people with dengue fever not to take aspirin. Acetaminophen or other over-the-counter pain-reducing medicines are safe for most people. For severe dengue symptoms, including shock and coma, early and aggressive emergency treatment with fluid and electrolyte replacement can be lifesaving.

The best way to prevent dengue fever is to take special precautions to avoid contact with mosquitoes. Several dengue vaccines are being developed, but none is likely to be licensed by the Food and Drug Administration in the next few years.

When outdoors in an area where dengue fever has been found Use a mosquito repellant containing DEET, picaridin, or oil of lemon eucalyptus 33

Dress in protective clothing-long-sleeved shirts, long pants, socks, and shoes

Because Aedes mosquitoes usually bite during the day, be sure to use precautions especially during early morning hours before daybreak and in the late afternoon before dark.

Other precautions include: Keeping unscreened windows and doors closed Keeping window and door screens repaired Getting rid of areas where mosquitoes breed, such as standing water in flower pots, containers, birdbaths, discarded tires, etc.

References
Meg Gulanick, Nursing Cared Plans, 6th edition, copyright 2007 Jean Foret Giddens et. al., Mosby PDQ for RN, 2nd edition, copyright 2008

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 Joyce M. Black et. al., Medical Surgical Nursing, 8th edition, copyright 2009 Barbara E. Gould, Pathophysiology for the Health Profession, 3rd edition, copyright 2006 Judith A. Schilling McCann et. al., Nursing 2007 Drug Handbook, copyright 2006 Sue E. Huether, Understanding Pathophysiology, 4th Edition, copyright 2008 Barbara C. Long, Medical Surgical Nursing, 3rd Edition, copyright 1993 Saul Kassin, Psychology, 2nd edition, copyright 1998 Camille B. Wortman et. al., Psychology, 3rd Edition, copyright 1988 Amy M. Karch, Focus on Nursing Pharmacology, 4th Edition, copyright 2008

Annex -A

Appendices

35

Christ the King College

Nursing Program
Gingoog City

Kardex

Name of Student: Leilani R. Ampo Year Level: 4th year BSN Date of Duty: January 3, 2012 Area of Duty: MOPH-Gingoog (Annex Bldg. Medical Ward)

Last name: Middle name: Dime, Balisry Age: 14 year old Address: Sex: Male Nationality Filipino

First name: Charlemagne Religion: Roman Catholic Civil Status Child Room/Bed #: 207(annex)

Purok 3 North Poblacion, Medina, Misamis Oriental Contact Number: Chief Complaints: Fever X 2 Date admitted Jan. 01, 2012 Time admitted: 10:15 AM

days Attending Physician: Hospital # Medical record # Dr. Harold R. 27-70-58 #5 Cagang Admission Impressions: Systemic Viral Illness R/I Dengue Fever Prognosis: Good prognosis as long as client complies with medication, have proper nutrition, maintains proper hygiene and oral fluid intake. And family can afford for a tertiary care hospitalization if complication arises.

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37

Date Ordered 1-1-12 DAT Date 1-1-12

Diet

Medication No dark colored Food Paracetamol 500 mg 1 tab q 4 PRN if

1-1-12

1-2-12 1-3-12

T 37.8 C Treatment: Vomited Consent to care signed I&O q shift Refer accordingly Continue meds Still for labs For tertiary referral

Laboratory Exams 1-1-12 CBC plt, u/a Remarks Date Time I.V. Fluids 1-2-12 Rpt CBC Ordered plt 3PM Rpt CBC D 0.3 Nacl 1-1-12 1-3-12 plt @ 20 gtts/min Rpt CBC D NM L @ SR plt
D NM L @ SR

Remarks

Date Ordered

Remarks Result in Result in Time on Result in

Time Consumed Remarks

Date Temperature:
Blood Pressure:

Heart Rate: Respiration Rate:

Reference: MOPH-GC card

Vital Signs and I & O 1-1-12 1-2-12 1-3-12 38.8C 37.8C 38.1C 90/60mmHG 120/70mmHG 120/80mmHg 90bpm 88bpm 92bpm 24cpm 25cpm 24cpm

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Annex-B

Christ the King College

Gingoog City

Nursing Program
Client Data Form Name of Student: Leilani R. Ampo January 3, 2012 Year Level:4th YR BSN Bldg. medical Ward) Clients Information Group:_________ Area: MOPH-Gingoog (Annex Date:

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Last name: Middle name: Dime, Balisry

First name: Charlemagne

Age: 14 year old Address:

Sex: Male

Nationality Filipino

Religion: Roman Catholic

Civil Status Child

Room/Bed #: 207(annex)

Purok 3 North Poblacion, Medina, Misamis Oriental Contact Number:

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Occupation: Attending Physician: Dr. Harold R. Cagang Admission Impressions:

Date admitted Time admitted: Jan. 01, 2012 10:15 AM Reason for Hospitalization (client quote) Fever X 2 days

Systemic Viral Illness R/I Dengue Fever Prognosis: Good prognosis as long as client complies with medication, have proper nutrition, maintains proper hygiene and oral fluid intake. And family can afford for a tertiary care hospitalization if complication arises. Family History (narrative)

Client was born second to the oldest among three siblings. The family has no health problems, except the mother is currently being monitored with her Hypertension which is induced due to her fourth pregnancy. However, Charlemagne is the first in the family being brought to hospital for such illness.

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Personal History: (narrative)

One day prior to his admission, the client said he was gallivanting at the neighbors place last December 31, 2011 (Saturday), and was caught by the rain. When he reached home he was having chills and hyperthermia. His parents decided to bring him to hospital since he was vomitus and having chills and with fever.

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Admission Data Client is from : Home: ___ Doctors Clinic; ___ School: ___ Work: ___ Other Hospital:___ Others: ___ ______________________________ ______________________________ ______________________________ Accompanied by: Parents Laboratory results from outside: Lipunan Hospital Inc., Jan.1, 2012, 10:00 AM Person to notify in case of emergency : Name: Gregorio Dime (Father) Address: Medina, Misamis oriental Contact #: _______________________________

Mode of Admission: Ambulatory; ___ Wheelchair: ___ Stretcher: ___ Others: ___ _________________________________ _________________________________ _________________________________ _________________________________ Valuables: None: ___ With Client: ___ Given to relatives: ___ List:____________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________

Assessment Tool Vital Signs Temperature: ___37.8 C____________ Axilla/Oral Pulse: _______88bpm______________ Radial/Brachial Apical Pulse: _____90bpm__________ Respiration: ____25cpm___________ Blood Pressure: 120/70mmHg__ Standing/Sitting/Lying Time BP taken:

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3:50 PM Height: __52 Measured/Estimated Weight: __57 kgs Measured/Estimated Allergies/Sensitive to: Any Allergy to Food/Medicine/Latex/others? ___yes

__no

If yes, Please specify: ________________________________ Have used Blood Products? Reactions? Cranial Nerve Assessment ___yes ___no ___yes ___no

1. Cranial nerve I Client has no difficulty identifying scents and aromas. 2. Cranial nerve II Client has no visual problems.

3. Cranial nerve III Clients pupils in both eyes have equal size and capable of following moving objects. 4. Cranial nerve IV 5. Cranial nerve V 6. Cranial nerve VI 7. Cranial nerve VII 8. Cranial nerve VIII 9. Cranial nerve IX 10. Cranial nerve X 11. Cranial nerve XI 12. Cranial nerve XII
Skin Skin Integrity/Condition intact Rash Lesion

Client can normally follow moving objects w/ both eyes. Facial muscles can move, can chew normally. Eyes can move actively and roll eyes laterally. Can close eyes normally and tongue has good sense of taste. Has good hearing sensation in both ears. No problem or difficulty of swallowing. Strong muscle strength in the head, shoulders, neck, and back. Capable of controlling tongue movement.
Color Normal Pale Cyanotic Flushed Moisture Diaphoretic Normal Dry

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Ulcer Bruising Scars Burns Describe: Petechiae seen after tourniquet test done 13-12 ____________________________ ____________________________ IV Access Peripheral Left Arm Central___________________ _ Head Hair infestations of lice. Lice Dandruff Lesions Bald Face found but face is flushed. Acne Scars Wounds/lesions Eyes: Vision No Impairment R/L Impaired R/L Blind Glass/Contact Lenses Color Describe:
Clear Yellow Red R/L Both eyes Drainage R/L N/A

Mottled Jaundiced Temperature Warm Hot Cool Cold Note: 37.8C 12 38.9C 1-3-12 1-2-

Mouth Pink/moist Ulcers Lesions Bleeding Lips Dry Cracked Intact Lesions

Describe: Client has clean hair and well kept. No

Client face is clean, no scars, no acne

Ear Hearing No Impairment R/L Impaired R/L hearing Aide Others ________________ ________________ ________________ ________________ ________________

Teeth Dentures Yes No Caries Brace Yes No Yes No

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Cardiovascular Neck Flat Distended Apical Pulse Regular Irregular Pacemaker Type: _____________ Rate: 90 bpm Heart Sound Normal Abnormal Note:____________________________ __ ______________________________________ Radial Pulse Strong R/L Faint R/L Doppler R/L (If Applicable) Note:______________________________

Brachial Pulse Strong R/L Faint R/L Doppler R/L (If Applicable) Pedal Pulse Strong R/L Faint R/L Doppler R/L (If Applicable) Edema No Yes Site: ____________________________ Numbness No Yes Site: Muscle & Joint Pains

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Respiratory Retractions N/A Supra Clavicular Intercostal Diaphragmatic Cough Describe: N/A Non-productive Productive Ability to clear secretions Yes No Breath Sounds Clear Adventitious: Equal Gastrointestinal Abdominal Soft Firm Rigid Distended Tenderness N/A Yes Location:_____________________ Bowel Sounds Present ___________Sounds/min. Absent Feed Independently Yes No Nasogastric tube/gastrostomy tube Yes No NGT date change:_________________

Tracheostomy Yes No Date inserted:_________________ Date tube change: _____________ Chest tube Yes No Location;_________________________ _ Oxygen Room Air Nasal cannula Face Mask Trach Mask Endotracheal tube BIPAP CPAP Constipation Yes No Diarrhea Yes No Date of last BM:___________ Appetite Good Fair Poor Nausea Vomiting Chewing/ Swallowing Difficulties Yes Describe: _________________ No _________________________

Extremities Upper Fingers Complete ______________________ Arthritis ______________________ Lower Toes Complete ______________________ Arthritis ______________________

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Callus _____________________ Nails Cyanotic Club Dirt Cut Arms Lesions Scars Arthritis Others Muscle pain & Joint Pain in the arms. Legs Nails

Callus _____________________ Cyanotic Club Dirt Cut Lesions Scars Arthritis Others Muscle pain & Joint Pain in the legs.

Genital and Anal Male Lice STI Not Applicable Catheter Hernia Others Female Lice STI Not Applicable Catheter Hernia Menstruation Date started: Not Applicable Date ended: Others ____________________________ _______________________________ ___ Anus Hemorrhoids STI Not Applicable

Anus Hemorrhoids STI Not Applicable

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49

Descriptive: Indicate all Observed in the diagram

Warm Skin Headache/ Nausea Red Eyes and Orbital Pain (Conjunctival Suffusion) Flushed face

Febrile Temperature 38.8C

Poor appetite Increase Breathing Rate: 25 cpm Body Weakness

Vomitus Feeling

Petechiae After Tourniquet Test Sweaty Palms IVF @ Left Arm D5 NM 1L @ 20gtts/min

Muscl e Pains Long Finger Nails/Dirty Joint Pains

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Annex-C

CHRIST THE KING COLLEGE Nursing Program Gingoog City

Nurses Health Teaching Tool Disease Process (Pathology of the disease)

Dengue fever is a potentially deadly infection spread by Aedes Aegypti Mosquitoes through salivary glands that enters human skin portals (biten). Dengue Virus inoculates in blood circulation and inoculates w/in 3 -14 days. Virus attacks Liver and Spleen and causes cell death and other complications such as Intense bleeding, Pulmonary Edema, Shock, Liver Cirrhosis and Death eventually.

Medication (12 Rs of medication)

No medications available that can provide a cure. Treatment addresses the symptoms and it also attempts to avoid potential complications. Non narcotic analgesic and antipyretics to decrease temperature or regulate pain. Antibacterial/Antiviral to prevent/treat infections. Antiemetics to treat vomiting. IVF for electrolytes loss (D5LR) Avoid Aspirin because of gastritis and bleeding tendencies.

Diet
Normal diet or Diet as tolerated to foster wasting of nutrient which patient unconsciously losses during sickness. NDCF (No dark colored food) or hemoglobin free diet that can interfere results for stools. Safe to serve: Cheese, milk, eggs, non-leafy vegetables, refined vegetables, fruits and fruit juices.

Daily Plan of activity

Rehydration w/ IVF to correct dehydration Administration of meds order Normal diet Keep sanitary environment to prevent infections & promote healing Bath daily to prevent invasion of microorganisms Clean body & change to clean clothes daily Maintain good oral and body hygiene Exercise Increase fluids intake Regular bowel movement 51

 Clean surroundings and spray insecticides Close containers when they collect water Proper garbage disposal

Follow ups Have a follow up consultation & regular check ups Proper way to take body temperature at home Have enough rest and avoid heavy strenuous activity Avoid alcoholic beverages while taking meds Emphasize importance of fluid intake Discuss use of antipyretics/antibiotics (overdoses can cause liver damage) Compliance to home medications Watch for signs and symptoms that require immediate medical attention

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Submitted by: Leilani Rodriguez-Ampo BSN IV

Thank You!

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