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Southeast Asian College, Inc.
College of Nursing
S.Y. 2010 2011
Submitted by:
Chester C. Lozano
CON 423 Group 11
Submitted to:
Mrs Elizabeth M Abanto
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I. BACKGROUNDOF THE STUDY
II. PATIENTS PROFILE
III. NURSING HISTORY
a. CHIEFCOMPLAINT
b. HISTORYOFPRESENT ILLNESS
c. HISTORYOFPAST ILLNESS
d. FAMILY HISTORY
IV. PHYSICAL ASSESSMENT
V. PATHOPHYSIOLOGY
VI. CLINICAL REPORT
VII. DRUG STUDY
VIII. NURSINGCARE PLAN
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I. Background of the Study
Dengue Fever (DF) is caused by one of four closely related, but antigenically
distinct, virus serotypes DEN-1, DEN-2, DEN-3 and DEN-4 of the genus flavivirus.
Infection with one of these serotypes provides immunity to only that serotypes of life, so
persons living in a dengue-endemic area can have more than one dengue infection
during their lifetime. Dengue Fever through the four different dengue serotypes are
maintained in a cycle involves humans and the Aedes mosquito through the
transmission of viruses to humans by the bite of an infected mosquito. The mosquito
becomes infected with dengue virus when it bites a person who has dengue and after
about a week can transmit the virus while biting a healthy person. Dengue cannot be
transmitted or directly spread from person to person. Aedes Aegypti is the most
common aedes species which is a domestic, day-biting mosquito that prefers to feed on
humans.
The principal symptoms of dengue are high fever, headache, backache, joint
pains, nausea and vomiting, eye pain and skin rash. Fever in symptomatic dengue fever
may be as high as 410C. The fever typically begins on the 3rd day and lasts 5-7 days,
abating the cessation of viremia. Fever is often preceded by chills, erythematous
mottling of the skin, and facial flushing. Occasionally, the fever abates for a day and
then returns, a pattern that has been called saddleback fever.
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All persons are susceptible in acquiring DF. Both sexes are equally affected. Age
groups predominantly affected are pre school age and school age. Adults and infants
are not exempted. Peak age affected 5 9 years.
DF is sporadic throughout the year. Epidemic usually occurs during rainy
seasons (June November). Peak months are September October. Occurs wherever
vector mosquito exists.
Patients Profile
Name: E.S.C
Address:414 T. Anzures St. Sampaloc Manila
Birthday: September24, 2004
Age: 6 years Old
Birthplace:Manila
Gender:Female
Height: 117cm
Weight: 18.5 kg
Civil Status: Single
Religion: Roman Catholic
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Case No.:
Final Diagnosis: Dengue Fever Syndrome
II. Nursing History
1. Chief Complain- FEVER
2. History of Present Illness
The patient condition started 5 days, PTA when patient had
undocumented fever.
No other symptoms noted such as cough, cold, vomiting, and no
consultation was done.
3 days PTA, still with fever, following sign and symptoms was noted
similar to headache, joint pain and 1 episode of epistaxis on the Left nostril CBC
was done.
3. Past Medical History
According to the father this was her daughters first hospitalization, no
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There are no histories of drug maintenance and accident, only common
illness that the patient had encountered. Their family also doesnt love traveling
to much.
4. Family Health History
According to the father, both sides of the family have history of diabetes
mellitus, no other history of illness in their family have been noted. It was their
first time to handle this kind of illness.
5. Socio Economic and Environmental History
According to the father, their environment is clean, there is no stagnant
water in their house, but he doesnt have an idea if its the same in her daughters
school. They provide mosquito repellant in their house. What their problem is
they have no idea about the sanitation of his daughters school.
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III. Physical Assessment
General appearance:
o Conscious, coherent, awake, oriented to place and people
Vital Signs:
o BT:38.4oC increased; due to increase cellular metabolism; increase circulating
pyrogens
o RR: 29 bpm normal
o
PR: 113 cpm normal
Body Part Inspection Palpation Percussion Auscultation
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Scalp
Forehead
Face
Eyes
Brows
Lashes
Sclera
Conjunctiva
Cornea
Iris
W/ slight
dandruff butno woundspresent
No scars, notoily, w/outwrinkles
Symmetrical,no presenceof scar, w/outwrinkles andpimples
Symmetrical,slightly
round, alignw/ the ears
Hair evenlydistributed,skin is intact,black in color
Short, black,turn outward
?
Pink in color
Shiny,transparent &smooth
Black incolor, round
Free fromany lesions
Notenderness, no lesions
Smooth, norashes, notenderness
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Vision
Nose
Mouth
Lips
Gums
Teeth
Tongue
Sublingualarea
slowly as itfollows my
sign
20/20 vision
Septum isaligned in themidline, nodischarge, no
obstruction,air flowsfreely
Open & closesymmetrically
Reddish incolor & dry
Intact,pinkish incolor, noswelling norbleeding
?
Positioncentrally,moist, slightlypinkish, no
lesions
Pinkish,visible veins
Whitish, bony
Nodeformities
nor lesions
No edema
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Tonsils
Ears
Neck
Lymph Nodes
Thyroid
Skin
Chest
Heart
small, alignwith the
eyes, pinnais inline withthe outercanthus ofthe ear, nosweeling
Good flexion,
extension &rotation
Not enlarged
No bulges
Faircomplexion,w/outwrinkles, nodryness
Equal chestexpansion,rise & fallduringrespiration isvisible
Soft & flat
No abnormal
Palpablecarotidpulse
Notpalpable
Moves up& down asthe patientswallows
Slightlycold, goodskin turgor
No nodules
Palpableapical
Clear lungsounds, norales orwheezes
PR = 61bpm
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Upper
Lower
MuscleStrength
T 36.5rC
symmetrical
Able toperformROMexercises
radialpulse, no
tenderness, slightlycold
Dry totouch
VI. Pathophysiology
PREDISPOSING FACTOR PRE DISPOSING FACTOR
Factor:
- Age:6 y/o
- female
Immunocompromised
host
Environment
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Infects cells & generate cellular response
Initiates destruction of the platelet
Potential for hemorrhage
Stimulates intense inflammatory response
WBC (Neutrophils & Macrophages) (Histatin,Kinins)
Release of endogenous pyrogens vascular response
Reset of hypothalamic thermostat Redness & Heat
The body releases anti-Release of exogenous
pyrogens
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Muscle contract Blood vessels
To produce construct to
Additional heat prevent loss of body heat
DEATH
SHIVERING CHILLS
V. Diagnostic Studies
I. Clinical ReportDate of examination: Dec 13, 2010
Type of examination:
Test Result Unit Reference
Hemoglobin 127 g/LMALE: 133177
FEMALE: 117157
CHILD (12y/o): 96156
NEWBORN: 180220
Hematocrit .37
g/L MALE: 0.400.52
FEMALE: 0.350.47
CHILD (12y/o): 0.340.48
NEWBORN: 0.480.68
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WBC
Neutrophil
Lymphocyte
Monocyte
Eosinophils
Basophils
Band
4.6
0.28
0.58
0.02
0.01
0.00
0.02
10^3uL 6y/o: 4.5012.00
1y/o: 6.0014.00
NEWBORN: 9.0030.00
ADULT: 0.400.70
CHILD: 0.300.60
ADULT: 0.200.40
CHILD: 0.300.60
0.020.10
0.010.04
0.00-0.01
0.050.10
Platelet Count 143 10^3uL 150100
MCV 78 fl
ADULT: 80100
CHILD (12y/o): 7692
NEWBORN:95125
MCH 26.80 Pg ADULT: 2734
CHILD (1y/o): 2331
MCHC 0.34 g/dL
ADULT: .31.36
CHILD (12y/o): .32.36
NEWBORN: .30.42
RDW 13.80 % 11.514.5
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IV. Clinical Report
Date of examination: December10, 2010
Type of examination:
Test Result Unit Reference
Hemoglobin 132 g/LMALE: 133177
FEMALE: 117157
CHILD (12y/o): 96156
NEWBORN: 180220
Hematocrit .39
g/L MALE: 0.400.52
FEMALE: 0.350.47
CHILD (12y/o): 0.340.48
NEWBORN: 0.480.68
RBC 4.99 10^6uL
MALE: 4.405.90
FEMALE: 3.805.20
CHILD (12y/o): 3.505.20
NEWBORN: 4.706.10
WBC
Neutrophil
3.1
0.46
10^3uL
ADULT: 4.5011.00
6y/o: 4.5012.00
1y/o: 6.0014.00
NEWBORN: 9.0030.00
ADULT: 0.400.70
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Monocyte
Band
0.19
0.020.10
0.010.04
0.050.10
Platelet Count 239 10^3uL 150100
MCV 79.00 fl
ADULT: 80100
CHILD (12y/o): 7692
NEWBORN:95125
MCH 26.50 Pg ADULT: 2734
CHILD (1y/o): 2331
MCHC .34 g/dL
ADULT: .31.36
CHILD (12y/o): .32.36
NEWBORN: .30.42
RDW 14.40 % 11.514.5
MPV 7.20 fl MALE: 7.39
FEMALE: 810
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V. Clinical Report
Date of examination: December13, 2010
Type of examination: Immunology and Serology Section
Assay Patients Result
Dengue Rapid Test IgM= POSITIVEIgG= POSITIVE
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VI. Drug Study
Name of Drug Action Indication Contraindication Adverse Effect NursingConsideration
Generic:
paracetamol
Brand:
Biogesic
Classification:antipyretics
Dosage:
~ Children
12yr should not
receive >5
doses/24 hrwithout
notifying the
physician or
other health
care
professional.
~ PO (Adultsand Children
>12yr): 325-
650mg q 4-6 hr
or1g 3-4 times
daily or
Inhibits the
synthesis of
prostaglandins
that may serve as
mediators of painand fever,
primarily in the
CNS. Has no a
significant and
anti-inflammatory
property or GI
toxicity.
Therapeutic
effects:
Analgesia.
Antipyresis.
Mild pain. Fever. Contraindicated
in: Previous
hypersensitivity;
Products containing
alcohol, aspartame,saccharine, sugar
or tartrazine should
be avoided in
patients who have
hypersensitivity or
tolerance to these
compounds.
Use cautiously in:
Hepatic
disease/renal
disease: Chronic
alcohol use/abuse:
Malnutrition.
GI: HEPATIC
FAILURE,
HEPATOXICITY
(overdose).
GU: renal failure
(high
doses/chronic
use).
Hemat:
neutropenia,pancytopenia,
leucopenia.
Derm: rash,
urticaria.
Pedi: Advise
parents or
caregivers to check
concentration of
liquid preparations.Errors have
resulted in serious
liver damage. Have
parents or
caregivers
determine the
correct formulationand dose foe their
child and
demonstrate how to
measure it using an
appropriate
measuring device.
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1300mg q 8 hr.
~ PO (Children
1-12yr):10-15mg/kg/
dose q 4-6 hr
as needed.
~ PO (Infants):
10-15mg/kg/
dose q 4-6 hr
as needed.
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VII. Nursing Care Plan
Assessment Diagnosis Planning Intervention Evaluation
Subjective:
Nilalamig ako, as
verbalized by the
patient.
Objective:
warm to touch
pale skin color
restlessness
increased bodytemperature
tachycardia
VS as follows:
T 38rCP 103bpmR 20cpmBP 110/80mmHg
Hyperthermia related
to illness secondary to
dengue as manifested
by increased in body
temperature (38rC)
After 2 hours of
nursing intervention,
the patient will
maintain core
temperature within
normal range.
Monitor VS
Perform TSB Note
presence/absenc
e of sweating asbody attempts toincrease heatloss
Instruct toincrease fluidintake
Administer
medication asprescribe by thephysician
Goal Met.
After 2 hours of
nursing intervention,
the patient was able
to maintain core
temperature within
normal range as
evidenced by T
37.2rC, pulse rate of
81bpm, able to sleepwell.
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Nursing Care Plan
AssessmentDiagnosis Planning Intervention Rationale Evaluation
SUBJECTIVE :
Lagi ako
nauuhaw as
verbalized by the
patient
OBJECTIVE :
- Dry lips and
mouth
- Poor skin
turgor
> Fluid Volume
Deficit
Related to
decreased
motivation to
drink liquids
secondary to
fatigue
After 2 days of
nursing
intervention,
Patient will
maintain fluid
volume at anamount optimum
for normal
functioning as
evidenced by a
normal urine
output with
normalspecific gravity,
stable vital signs,
moist mucosa
Vital signs taken
Monitor I and O
Anticipate fluid
replacement by
preparing
peripheral
route for IV
transfusion.
Encourage fluid
intake by placing
a
glass of juice or
water
to have good
baseline data
to have good
baseline data
Provide route
for IV fluid
replacement to
save time and
decrease risk for
complications.
Best way to
encourage fluid
intake. DHF
patient are always
thirsty prior to thedefervescence
stage.
Monitoring for
trends for 2 to 3
days gives a more
Aftet 2 Days
after a series of
nursing care, the
patient
manifested a
normal urineoutput of 30ml
per hour with a
specific gravity
of1.011. Stable
Vital signs were
monitored andrecorded. CRT
was recorded
normal. Physical
assessment
revealed no sign
of fluid deficit
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within the
patients
reach.
Monitor total fluid
intake and output
every 2 hours
valid picture of
the client's
hydration statusthan monitoring
for a shorter
period.