CASE PRESENTATION

JOHN EDWIN E. PACIA

CMMC NURSING BATCH 2022
Patient’s Personal Data

Name: Rebortuva, Krizza Mae. Cadacio

Age: 18
Address: 2 Payna st, Proj 7. Quezon City
Sex: Female
Civil Status: Single
Religion: Roman Catholic
Birthday: July 17, 2001
Room and Bed no.: 523
Hosp no.: 277124
Attending Physician: Dr. Henson
 MEDICAL DIAGNOSIS

Systemic Viral Illness R/O DENGUE FEVER

Dengue (pronounced DENgee) fever is a painful,
debilitating mosquito-borne disease caused by
any one of four closely related dengue viruses.
These viruses are related to the viruses that
cause West Nile infection and yellow fever.
 CHIEF COMPLAINT

 2-3 weeks cold took neozep q8 a day

 1 week po, dry cough & colds

 2 days po. 39.3*c bago pumunta dito

 Still with headache scale of 7/10

 MEDICAL HISTORY
 History of Present illness: 3 WEEKS COLD, 1
WEEK DRY COUGH & COLD, 2 DAYS 39*C
BEFORE HOSPITALIZATION WITH HEADACHE
SCALE 7/10
 Past Medical History: UNREMARKABLE
 SOCIAL HISTORY: PUYAT PALAGI
 ENVIRO HISTORY: OFTEN EXPOSED TO
POLLUTION
 Family Medical History: Diabetes (father)
 GORDON’S 11 FUNCTIONAL HEALTH PATTERN

HEALTH PATTERNS BEFORE DURING INTERPRETATION

HOSPITALIZTION HOSPITALIZATION
HEALTH SHE PERCEIVES SHE PERCEIVES HER HEALTH
PERCEPTION HER HEALTH IS IN HERSELF AS AN PERCEPTION
GOOD CONDITION UNHEALTHY AND CHANGED DUE TO
FATIGUED OR TIRED HER ILLNESS
PERSON
NUTRITION -She loves to eat She eats now
processed foods vegetables
and street foods especially chopsuey
such as and some fruits
siomai,kwek such as
kwek,ice scramble apple,banana etc
and others
This time she
-Seldom drinks frequently drinks
water because she water
love C2 than H2O
ELIMINATION Defecates least Defecates minimal The doctor
twice a day watery stool prescribed an
Urinates 5-6 a day Urinates 2-3 a day increase in fluid
intake to maintain
adequate hydration
SLEEPING PATTERN Sleeps at least 4-6 She wakes up every The patient
hours a day now and then experience
disturbance of sleep
due to her illnes
COGNITIVE She can She experience The patient has
PERCEPTUAL comprehend well difficulty in difficulty of
PATTERN responds communicating to response du to his
appropriately to other people illnes resulted in
verbal & physical communication
stimuli difficulty
SELF PERCEPTION Perceived herself as Perceived herself a The patient did not
a very good friend a good friend and a experience a
and a daughter daughter change i her self-
perception despite
her illnes
ROLE-RELATIONSHIP She is able to do her She’s not able to do The patient needs
PATTERN responsibilities as a her responsibilities bed rest
student, daughter
and a older sister
Sexual Reproductive Metruates every Metruates every The patient’s
Pattern month for 4-5 days month for 4-5 days medical conditon did
and consumes at and consumes at not affect her sexual
least 3-4 pads per least 3-4 pads per reproductive pattern
day day

COPING STRESS She copes up She copes up The patient

AND with stressors with stressors copes up with
TOLERANCE by surrounding by surrounding stressors and
PATTERN herself with herself with illness
good people anf good people anf appropriately
managing her managing her
time properly time properly
ACTIVITY EXERCISE She wakes up every She stays home to The patient needs
PATTERN morning to attend take care of herself adequate rest and
school and atleast and rest and least sleep
look after to her check her younger
younger sister sister
VALUE-BELIEF She attends Church She attends Church The patient
PATTERN every Sunday with every Sunday with condition did not
her mom and sister her mom and sister affect their value-
belief pattern
 PHYSICAL EXAMINATION
BODY PART NORMAL FINDING ACTUAL FINDINGS ANALYSIS/
INTERPRETATION
LIPS PINKISH AND DRY MOUTH OR DEHYDRATED
MOISTURED CRACKLED TEXTURE
OF LIPS

EXTREMITIES EVEN FAIR SKIN UNEVEN FAIR SKIN, Unremarkable

COLD AND CLAMMY
TO TOUCH

URINARY SYSTEM Adequate or usual Decreased Urination DEHYDRATION

urination volume
and duration

BODT TEMP SHOULD BE 36.6*C- 39.3*C INCREASED BODY

37.6*C TEMP DUE TO HIS
FEVER
 LIST OF NSG DIAGNOSIS(NANDA)
CUES NURSING DIAGNOSIS JUSTIFICATION

Subjective: Characteristics
“MASAKIT ULO KE’’ HYPERTHERMIA SUBJECTIVE:
headache,dizziness
OBJECTIVE: Objective:
BODY TEMP: 39.3*C Increase in body
temperature above normal
range
Flushed skin; warm to touch
Increased respiratory rate,
tachycardia [‘unstable BP]
Seizures or convulsions;
[‘muscle rigidity/
fasciculation]
Subjective: Definition: Decreased
Uminom naman ako DEHYDRATION intravascular, interstitial,
dalawang summit na and /or intracellular fluid,
ganyan (330ml) -Deficient Fluid this refers to dehydration,
Volume Intake water loss alone without
Objective : change in sodium
Inadequate fluid SUBJECTIVE: thirst,
consumption weakness
OBJECTIVE: ALTERATION in
skin or tongue ; dry skin or
mucous membrane
Decrease in urine output
Increase in body
temperature and heart rate
SUBJECTIVE: Definition: Intake of
Kumain naman ako kahit IMBALANCED NUTRITION: nutrients insufficient to
konti LESS THAN BODY meet metabolic needs
REQUIREMENTS
Objective: Subjective: Insufficient
The meal that was given interest in food; food
was barely or consumed aversion; alteration in taste
inapropriately sensation; perceived
inabilitity to ingest food

Objective: Body weight 20%

or more below ideal weight
range; [‘decreased
subcutaneous fat or muscle
mass]
Food intake less than
recommended daily needs
Thank you!!!