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DENGUE

HEMORRHAGIC FEVER
ZOILO ZERNA KHAZMERA AMPAO ASNIM AMER JOSEPH CALLET LESLEE EMATA SHEENA CLAIRE GENTALLAN JUNAIMA D. MACKNO BSN-4D

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OUTLINE:
I. II. III. IV. V. Case Presentation Objectives Introduction Definition of Terms Vital Information Assessment a. b. c d.. e. VI. VII. VIII. Nursing History Genogram Gordons Assessment of Functional Health Patterns Physical Assessment and Review of System Diagnostic Test

PAGES
3 4 9 11

12 14 15 19 24 31 40

Normal Anatomy & Physiology Risk Factors and Pathophysiology (CONCEPT MAP) Nursing Management a. b. c. Nursing Care Plans Health Education Plan Discharge Plan

41 50 52 54 58

IX. X. 3 |Page

Medical Management Prognosis

XI.

Bibliography

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I. OBJECTIVES

Within 1 hour and a half of case presentation: Presenters will be: Able to discuss the disease process (Dengue Hemorrhagic Fever): the causes, effects, management, treatment, and possible preventions. Able to determine and discuss briefly the grades of DHF Able to determine why certain management and medications are given and provided for the condition. Able to discuss how and why certain diagnostic tests are done for the condition. Able to provide health teachings to the patients family about certain interventions in the maintenance of health care. Able to develop plan of care for the client with Dengue Hemorrhagic Fever.

Students or audience will be able to: Learn the underlying causes of the Dengue Hemorrhagic Fever Know the manifestations of patient having Dengue Hemorrhagic Fever.

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Recognize the cause and risk factors of Dengue Hemorrhagic Fever. Identify at least 6 nursing diagnosis out from the assessment data gathered. Enumerate nursing interventions appropriate for the diagnosis

II. INTRODUCTION
Dengue fever and dengue hemorrhagic fever are acute febrile diseases. Dengue is classified as mild, moderate and severe depending on symptoms manifested. It also has grading and staging from grade 1-4 based on severity and condition. Dengue hemorrhagic fever (DHF), a potentially lethal complication, was first recognized in the 1950s during the dengue epidemics in the Philippines and Thailand. Dengue Fever is caused by one of the four distinct virus serotypes Dengue type 1,2,3 and 4 of the Genus Flavivirus and Chikungunya Virus. Infection with one of this serotype provides immunity to only that serotype of life, to a person living in a Dengue-endemic area can have more than one Dengue infection during their lifetime. Dengue serotypes are transmitted by AedesAegypti through bite. It becomes infected with the Dengue Virus when it bites a person who has Dengue and after incubation period of 6-10 days transmits the virus to healthy person. Dengue may also be transmitted via infected blood products, it cannot be transmitted or directly spread from person to person. The WHO says 2.5 billion people, are now at risk from dengue and estimates that there may be 50 million cases of dengue infection worldwide every year. All persons are susceptible and both sexes are equally affected. Dengue Fever is sporadic throughout the year. Epidemic usually occurs during rainy seasons (June-November) peak months are September-October. Dengue fever is a disease caused by a family of viruses that are transmitted by mosquitoes. It is an acute illness of sudden onset that usually follows a benign course with symptoms such as headache, fever, exhaustion, severe muscle and joint pain, swollen glands (lymphadenopathy), and rash. The presence (the "dengue triad") of fever, rash, and headache (and other pains) is particularly characteristic of dengue. Other signs of dengue fever include bleeding gums, severe pain behind the eyes, and red palms and soles. Clinical manifestation of Dengue Fever
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Severe type are frank type flushing, sudden high fever, severe hemorrhage, followed by sudden drop of temperature, shock and terminating in recovery or death. For moderate type high fever and spontaneous bleeding are present. For mild slight fever, with or without petechial hemorrhage are evident. The mainstay of treatment is timely supportive therapy to tackle circulatory shock dueto hemoconcentration and bleeding.

Dengue can affect anyone but tends to be more severe in people with compromised immune systems. Because it is caused by one of four serotypes of virus, it is possible to get dengue fever multiple times. However, an attack of dengue produces immunity for a lifetime to that particular serotype to which the patient was exposed. Dengue goes by other names, including "breakbone" or "dandy fever." Victims of dengue often have contortions due to the intense joint and muscle pain, hence the name breakbone fever. Slaves in the West Indies who contracted dengue were said to have dandy fever because of their postures and gait. Dengue hemorrhagic fever is a specific syndrome that tends to affect children under 10 years of age. It is a more severe form of the viral illness. Symptoms include headache, fever, rash, and evidence of hemorrhage in the body. Petechiae (small red or purple splotches or blisters under the skin), bleeding in the nose or gums, black stools, or easy bruising are all possible signs of hemorrhage. This form of dengue fever can be life-threatening and can progress to the most severe form of the illness, dengue shock syndrome. Pneumonia is common, and inflammation of the heart (myocarditis) may be present. The patient has increased vascular permeability and abnormal homeostasis (homeostasis is the maintenance of equilibrium, or constant conditions, in a biological system) that can lead to hypovolemia (abnormal decrease in blood volume) and hypotension (drop in blood pressure), and in severe cases, result in hypovolemic shock (Shock due to a decrease in blood volume) often complicated by severe internal bleeding. DHF starts abruptly with high continuous fever and headache. There are respiratory and intestinal symptoms with sore throat, cough, nausea, vomiting, and abdominal pain. Shock occurs two to six days after the start of symptoms with sudden collapse, cool, clammy extremities (the trunk is often warm), weak pulse, and blueness around the mouth (circumoral cyanosis). Vectors

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Aedesaegypti Dengue viruses are mainly transmitted by the bite of infected Aedesaegypti mosquitoes; an invasive, domestic species with tropical and subtropical worldwide distribution that originated in Africa.

Aedesalbopictus Another important mosquito vector of dengue is Aedesalbopictus, which is also an invasive species originally from Asia. Transmission The Aedesaegypti mosquito is the primary vector of dengue. The virus is transmitted to humans through the bites of infected
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female mosquitoes. After virus incubation for 410 days, an infected mosquito is capable of transmitting the virus for the rest of its life. Infected humans are the main carriers and multipliers of the virus, serving as a source of the virus for uninfected mosquitoes. Patients who are already infected with the dengue virus can transmit the infection (for 45 days; maximum 12) via Aedes mosquitoes after their first symptoms appear. The Aedesaegypti mosquito lives in urban habitats and breeds mostly in man-made containers. Unlike other mosquitoes Ae.aegypti is a daytime feeder; its peak biting periods are early in the morning and in the evening before dusk. Female Ae.aegypti bites multiple people during each feeding period. Aedesalbopictus, a secondary dengue vector in Asia, has spread to North America and Europe largely due to the international trade in used tyres (a breeding habitat) and other goods (e.g. lucky bamboo). Ae.albopictus is highly adaptive and therefore can survive in cooler temperate regions of Europe. Its spread is due to its tolerance to temperatures below freezing, hibernation, and ability to shelter in microhabitats. The virus is contracted from the bite of a striped Aedesaegypti mosquito that has previously bitten an infected person. The mosquito flourishes during rainy seasons but can breed in water-filled flower pots, plastic bags, and cans year-round. One mosquito bite can cause the disease. Characteristics of an Aedesaegypti mosquito: 1. 2. 3. 4. Daybiting Low-flying Live in stagnant water In urban area

The virus is not contagious and cannot be spread directly from person to person. There must be a person-to-mosquito-to-another-person pathway. Stages of Dengue Hemorrhagic Fever
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Grade I: fever + Herman's sign (flushes and redness of skin with lighter color at the center of the rash) Grade II: Grade I symptoms + bleeding (epistaxis or nosebleeding, gingival bleeding, hematemesis or upper gastrointestinal bleeding; e.g: vomiting of blood), and melena or dark stool. Grade III: Grade II + Circulatory Collapse (hypotension, cold clammy skin and weak pulse) Grade IV: Grade III + Shock.

Characteristics of DHF After being bitten by a mosquito carrying the virus, the incubation period ranges from three to 15 (usually five to eight) days before the signs and symptoms of dengue appear in stages. Dengue starts with chills, headache, pain upon moving the eyes, and low backache. Painful aching in the legs and joints occurs during the first hours of illness. The temperature rises quickly as high as 104 F (40 C), with relatively low heart rate (bradycardia) and low blood pressure (hypotension). The eyes become reddened. A flushing or pale pink rash comes over the face and then disappears. The glands (lymph nodes) in the neck and groin are often swollen. Fever and other signs of dengue last for two to four days, followed by a rapid drop in body temperature (defervescence) with profuse sweating. This precedes a period with normal temperature and a sense of well-being that lasts about a day. A second rapid rise in temperature follows. A characteristic rash appears along with the fever and spreads from the extremities to cover the entire body except the face. The palms and soles may be bright red and swollen. Dengue shock syndrome (DSS) results from leakage of plasma into the extravascular compartment. Rapid and poor volume pulse, hypotension, cold extremities, and restlessness occur. In addition to the plasma leakage, which is the result of generalized vasculitis, disseminated intravascular coagulation is present. Dengue shock syndrome is usually a progression of dengue haemorrhagic fever and is often fatal. The four serotypes of dengue virus that have 60-80% homology to each other. Infection with one dengue serotype provides lifelong homologous immunity but limited heterologous immunity. Almost all patients with DHF have had previous experience with at least one of the four serotypes of dengue viruses. Upon infection, the immune response produced specific antibodies to that subtype's surface proteins that prevent the virus from binding to macrophage cells (the target cell that dengue viruses infect) and gaining entry. However, if another subtype of dengue virus infects the same individual, the virus will activate the immune system to attack it as if it was the first subtype. Antibodies are produced to combat the sub type previously encountered. These antibodies bind to the surface proteins but do not inactivate the virus. The immune response attracts numerous macrophages, which the virus proceeds to infect because it has not been inactivated. The hypothesis that heterotypic antibodies from a previous dengue virus infection promote increased viral replication within mononuclear leukocytes by antibody-dependent enhancement, causing the symptoms to be much more serious. The body also
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releases cytokines that cause the endothelial tissue to become permeable, which results in hemorrhagic fever and fluid loss from the blood vessels The mortality (death) rate with DHF is significant. With proper treatment, the World Health Organization estimates a 2.5% mortality rate. However, without proper treatment, the mortality rate rises to 20%. Most deaths occur in children. Infants under a year of age are especially at risk of dying from DHF The WHO says 2.5 billion people, are now at risk from dengue and estimates that there may be 50 million cases of dengue infection worldwide every year. All persons are susceptible and both sexes are equally affected. Dengue Fever is sporadic throughout the year. Epidemic usually occurs during rainy seasons (June-November) peak months are September-October.

III.

DEFINITION OF TERMS

Cyanosis: A bluish color of the skin and the mucous membranes due to insufficient oxygen in the blood. For example, the lips may show cyanosis. Cyanosis can be evident at birth, as in a "blue baby" who has a heart malformation that permits blood that is not fully oxygenated to enter the arterial circulation. Cyanosis can also appear at any time later in life. Dengue shock syndrome: A syndrome due to the dengue virus that tends to affect children under 10, causing abdominal pain,
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hemorrhage (bleeding) and circulatory collapse (shock). Known also as dengue hemorrhagic fever (DHFEndemic: Present in a community at all times but in relatively low frequency. Something that is endemic is typically restricted or peculiar to a locality or region. Immune: Protected against infection. The Latin immunis means free, exempt. Immunity: The condition of being immune. Immunity can be innate (for example, humans are innately immune to canine distemper) or conferred by a previous infection or immunization. Incubation period: In medicine, the time from the moment of exposure to an infectious agent until signs and symptoms of the disease appear. For example, the incubation period of chickenpox is 14-16 days. Myalgia: Pain in a muscle; or pain in multiple muscles. Myalgia means muscle pain. There are many specific causes of various types of myalgia. Myalgia can be temporary or chronic. Myalgia can be a result of a mild conditions, such as a virus infection, or from a more serious illness. Examples include epidemic myalgia and polymyalgia rheumatica. Petechiae: Pinpoint flat round red spots under the skin surface caused by intradermal hemorrhage (bleeding into the skin). Petechiae are red because they contain red blood that has leaked from the capillaries into the skin. Petechiae are quite tiny (less than 3 millimeters in diameter) and do not blanch when pressed upon. Rash: Breaking out (eruption) of the skin. Medically, a rash is referred to as an exanthem. Serotype: The kind of microorganism as characterized by serologic typing (testing for recognizable antigens on the surface of the microorganism). Yellow fever: An acute systemic (bodywide) illness caused by a virus called a Flavivirus. In severe cases, the viral infection causes a high fever, bleeding into the skin, and necrosis (death) of cells in the kidney and liver. The damage done to the liver from the virus results in severe jaundice which yellows the skin.Hence, the "yellow" in "yellow fever." Abdominal pain: A condition which is characterized by the sensation of pain that is located in the abdomen. Dengue fever: An acute viral disease characterized by fever, rash and myalgia and caused by a flavivirus which is transmitted by mosquitoes. Dengue hemorrhagic fever: Severe complication of dengue
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Viral Hemorrhagic Fevers: Viral infections causing hemorrhagic fever (i.e. bleeding) Viral diseases: Any disease that is caused by a virus

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IV.

VITAL INFORMATION

Name: Little K! Room Number: 242 - 7 Age: 6 y/o Gender: Female Civil Status: single Date of Birth: March 15,2005 Cultural Group:Iliganon Primary Language: Cebuano Religion: Roman Catholic Highest Educational Attainment: still in Grade 1 Occupation: student Usual Health Care Provider: Physician Reason for Health Contact: For further management Date of Confinement: February 10,2012 3:30 am Source of History:Chart =
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SO =

70%

Attending Physician:Dr.Riza (Pediatrician) (Cardio-peditrician)

F.

Canoy M.D. Dr.Dy Chu Tee

Final Diagnosis: Dengue Hemorrhagic Fever Grade-3 Description of Patient:

Day 1: Awake, lying on bed, conscious, coherent, playful, oriented to time, place and people, well groomed, dress appropriate to her age, skin warm to touch, good skin turgor, CRT<3sec, with patent IVF of D5NSS 1L @ 10 ugtts/min hooked at right metacarpal vein infusing well, with non-productive cough, not in respiratory distress, strong peripheral pulses, afebrile T-36.1 C, PR- 100, RR 36, BP 90/60 mmHg. Day 2:

30%

Awake lying on bed, conscious, coherent, playful, oriented to time, place and people, well groomed, dress appropriate to her age, skin warm to touch, good skin turgor, CRT <3secs, with patent IVF of D5IMB 500 cc @

40ugtts/min hooked at right metacarpal vein infusing well, not in respiratory distress, afebrile T-35.7 C, PR-90, RR- 30, BP 100/70 mmHg.

V. ASSESSMENT

A. NURSING HISTORY

Chief Complaints/Reason for Visit:

SO verbalized that her daughter was complaints of on and off fever T-39.9, abdominal pain 8/10 associated with 3 episodes of vomiting, LBM yellow, non-mucoid.

History of Present Illness:

2 weeks PTA patient started fever of 38.0 39.8 C associated with chills, sweating temporarily relieved by paracetamol
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syrup of 5ml every 4 hours. On the next day she took a bath knowing that she was relief.

2 days PTA fever started again T-39.9 thus seek for consultation at City Heath and advised for U/A which result to infection. Given with cotrimazole of 5ml TID.

6 hours PTA patient manifested 3 episodes of vomiting, body malaise, loss bowel movement, abdominal pain of 8/10, pale lips and pale conjunctiva, thus prompted for admission at MSH.

History of Past Illnesses:

Little K! had a measles when she was 2 y/o and did not seek any consultation for it was subsides after a weeks.

Last September 2005 after fiesta Little K! hospitalized at Mercy hospital at 7 months old due to fever and diarrhea and it was diagnosed of amoeba, medications and the doctor who handle her cant recalled by the SO.

Last 2007 she had undergone minor operation Left anterior foot about 4 stitches at Gregorio T. Lluch Memorial Hospital due to playing bottles of coke during birthday of her twin sister.

Last 2008 she had diagnosed primary complex by Dr. Mariano and was treated 6 months therapy of Rifampacin, Iosiniazide, and Pyrazinamide and the mother cant recall the dosage of the medications. After being treated she had a regular check-up for further assessment and later part she had no regular check-up.
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Little K! had completed immunizations at Brgy. Health center and she had an allergy to egg. She had taken vitamins Ceeline but not compliant.

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B. GENOGRAM
PATERNAL MATERNAL

42 41 y/o

y/o

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6 y/o Legend: Female Male Patient RA

13 y/o

heart attack

DM

Deceased

DHF

alive

SO cant remember

C. GORDONS ASSESSMENT
Health Perception/ health management Pattern Reason for admission:

Patient was admitted due to complaints of fever T-39.9, abdominal pain associated of 3 episodes of vomiting, LBM. Her mother verbalized that patient understanding of the purpose of her admission to the hospital and the treatment received at the hospital means that she will be able to be treated with her illness.

Few years Before diagnosed DHF G3 Nutritional/metabolic pattern Patient had a good appetite; she ate 3 meals a day with occasional snacks in between meals. Patient had allergy to egg. She likes to eat fried chicken and junk foods. She occasionally goes to some local fast foods like; Jollibee, McDonalds, Chowking
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After diagnose DHF G3 and during hospitalization Nutritional/metabolic pattern She had poor appetite upon admission and prescribed Diet For Age. She occasionally had snacks in between meals such us apples and orange. Patient did not complaints of problem upon chewing and swallowing foods. She had tooth decay upper and

together with her mother and twin sisters. She has a vitamin intake of Ceeline but not compliant to it. Patient did not have complaints for problems in chewing and swallowing foods. She had tooth decay upper and lower teeth.During those years she drinks 6-8 glasses of water every day and often intake of softdrinks.

lower teeth. She instructed to increase fluid intake.

Elimination pattern

Patient had experienced diarrhea prior to admission described as yellow non mucoid and during hospitalization she defecates Elimination pattern twice since admission-brown, firmed stool. Her urination pattern is normal and is measured depending how much IVF intake and Patient had a regular BM pattern and she usually defecates fluid she drinks. She had rashes upon admission but does not everyday describing the stool as a normal; a brown, firmed experiences excessive sweating and abnormal body odor. stool. She does not had any problem upon on her bowel movement. She also had a normal urination pattern and measured the amount of urine output depending on how much fluid intake she had. Patient did not complaint of any skin Exercise and Activity Pattern problem and neither experienced excessive sweating and During her admission all she can do is to play cellphone at her abnormal body odor. bed. And sometimes go outside for walking and sitting in chair watching people walk in and out in the hospital and also Exercise and Activity Pattern watching staff nurses at the station. Patients typical day before started 5:30 am for school and during weekends around 9am. At school she always play with her classmates and after school she also play with her twin Sleep/rest Pattern sisters and do her homework. During weekends she played along with her neighbor. She loves to watch TV especially the Patients usual time of arising is 5:00 - 6:00am and primetime of ikawangpag.ibig. 8:00pm 9:00pm is her usual time to retire. She usually takes a nap if bored for at least 1 hour and 30 minutes. She sometimes Sleep/rest Pattern had nightmares and sometimes wake up in the middle of the Patients usual time of arising is 5:30 am -6am preparing night. for school during weekdays. She usually sleeps by around Cognitive/perceptual Pattern 9:00pm after doing her homework. She took a nap for at least
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30 minutes to 1 hour during afternoon after school. She usually During admission still she didnt experience blurring, has nightmares and not suffered from insomnia. pain, inflammation or any disorders involving the eyes. She also didnt experience hearing problems or any discomforts and Cognitive/perceptual Pattern abnormal discharges. Patient can easily feel pain; especially she She didnt experience blurring, pain, inflammation or any is afraid of injections, changes in body and environmental disorders involving the eyes. She also didnt experience hearing temperature. She can also distinguish objects through touch, problems or any discomforts and abnormal discharges. Patient able to tell the difference of smell and taste. can easily feel pain, changes in body and environmental temperature. She can also distinguish objects through touch, able to tell the difference of smell and taste. Values and Belief Pattern Environmental/ Hazards Even Little K! is just a child and just a 6 yr old, she said that she believed in God and has a fear for Him. She, Patients house is near dump site area. Their neighborhood together with her family goes to church every sunday. There's is congested and therefore risk for fire hazard. This kind of no problem with spirituality of the family. environment, their location is prone of pollution and therefore not conducive for healthy living. Values and beliefs Pattern Even Little K! is just a child and just a 6 yr old, she said that she believed in God and has a fear for Him. She, together with her family goes to church every sunday. There's no problem with spirituality of the family.

MMDST (METRO MANILA DEVELOPMENTAL SCREENING TEST)

Screening is the presumptive identification of an unrecognized disease or defect by the application of tests. Screening test sort out

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apparently well person who probably have the problem from those who probably do not. One such screening test is the metro manila development screening test (MMDST). It is an early detection model that applies to the detection of developmental disabilities in children aged six and half year old and younger. The MMDST is a simple, clinically usefull tool used in the early detection of children with serious developmental delays developed by Dr. Phoebe D. William. If evaluates four aspects of a childs development: personal-social, fine motor, adaptive language, and gross motor behavior.

Personal-social tasks which indicate the childs ability to get along with people and to take care of himself. Fine motor tasks which indicate the childs ability to see and to use the his hands to pick up objects and draw. Language indicate the childs ability to hear, follow direction and to speak. Gross motor task which indicates the childs ability to sit, walk and jump. SCHOOL AGE AND DEVELOPMENT According to Erik Erikson Developmental stages , Little K! belong to Industry vs. Inferiority. During this stage, often called latency, is capable of learning, creating and accomplishing numerous new skills and knowledge, thus developing a sense of industry. This is also very social stage of development and if experience unresolved feelings of inadequacy and inferiority among peers, can have serious problems in terms of competence and self-esteem. As the world expands a bit, our most significant relationship is with the school and neighborhood. Parents are no longer the complete authorities they once were, although they are still important.

*Birthday: March 15, 2005 Age Physical and motor Mental Adaptive Personal-social

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6 years old

Central mandibular incisors erupt Losses first tooth Active age, constant acitvity Often returns to finger feeding

Knows whether it is morning or afternoon Defines common objects such as fork and chairs in terms of their use Knows right and left hands Says which is pretty and which is ugly of a series of drawing of faces Attends first grade

At play, cuts, folds and paste paper toys Takes bath without supervision, performs bedtime activity alone Giggles a lot Tries out own abilities

Can share and cooperate better Has a great need for children of own age Often engage in rough play Often jealous of younger sisters Does what adults are seen doing May have occasional temper tantrums Has own way of doing things

D.PEROS

Day 1
General Survey: awake, lying on bed, conversant, interact well, cooperative, with patent IVF of D5NSS 1L @ 40cc/hr hooked at right metacarpal vein, head is symmetric, no deformities noted in the face, appearance appropriate to age, both upper and lower extremities are symmetric, not in slump 22 | P a g e

posture, weight- 20kg. height- 117cm, arm circumference- 7inches, no signs of distress, afebrile . Areas Assessed Integumentary System Subjective Findings ok namansiya run nawalanamaniyangmg a rashes sapanit as verbalized by the S.O Objective Findings Skin uniformly, brownish in color, warm, dry, intact, good skin turgor, no lesions, birthmarks and edema, no rashes noted, hair normally distributed, no clubbing of nails or discolorations, nail beds pink in color and firm w/ prompt capillary refill CRT< 2 sec., HEENT a.Head and face b.Eyes c.Nose e.Oral cavity dili man sakitakongngipon as verbalized by the pt. Normocephalic, no lesions and lumps noted, long black hair, no lice noted, no dandruffs noted, Face symmetric, no facial drooling noted, -pupil equally reactive to light and accommodation, pinkish conjunctivae, white sclera, no lesion or redness noted -pinna no mass, lesions, scaling, discharge or tenderness, - nose no deformities, nares patent, no epistaxis noted -mucosa and gingival pink, no lesions, no bleeding of gums -loose upper front teeth, multiple dark spots on most upper teeth, tongue in midline, no lesions Neck supple w/ full ROM, symmetric, no palpable lymph nodes, no lump and masses noted, no tenderness, no vein distention, palpable carotid pulse, trachea in midline No problem identified Problem Identified No problem Identified

Neck

dili man sakitilihokas verbalized by the pt.

No problem identified

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Respiratory System

walanamansiyagiubo run as verbalized by the SO.

Equal chest expansion, no crackles , wheezes, not in respiratory distress, no cough noted, RR-23-30bpm Chest X-ray result reveals: As compared to previous chest film dated 2-11-2012, there is significant decrease in the right pleaural fluid, now small in volume and subpulmonic in location w/ inter-fissural seepage

Risk for Impaired Gas Exchange Risk for infection

Cardiovascular System

dili man sakitakongdughan as verbalized by the pt.

No murmurs, apical impulse at 5th ICS in the left MCL, irregular heartbeat noted BP:100/70 PR-80-87 CRT> 2 sec.

Risk for decrease cardiac Output

Breast and Axilla Gastrointestinal System and the abdomen

No complaints made

Symmetric, no retraction, discharges or lesion, no masses or tenderness, no lymphadenopathy Normoactive bowel sound, 10clicks/quadrants, round , soft, non tender, no mass , lesions noted, no abdominal pain as claimed Abdominal girth-22 inch. Oral intake=350 IV=230 BM once moderate in amount, formed, brownish stool

No problem identified

karun pa nibalikganaiyangpagkaon as verbalized by the SO.

Risk for imbalance Nutrition: less than body requirement

Genitourinary/Reproducti ve System 24 | P a g e

dili man sakitpag mu ihiko as verbalized

Urinated 3x with dark yellowish color of urine, no foul odor,

No problem identified

by the pt.

negative of hematuria Total output=390 cc

Musculoskeletal System

dlili man luyaakongpamati run as verbalized by the pt. grade one namanko, gusto nakomoulisabalay

Full ROM, no limitation of movement, muscle grade 5/5 in both upper and lower extremities, no body weakness noted as claimed, no deformities noted Conversant, oriented to time ,place and person, intact cranial nerves Developmental Stage: -Can count numbers -defines common objects -Obeys triple commands in succession -Knows left and right -Attends first grade -able to solve simple arithmetic -able to spell simple words T-35.7-36.3 0C

No problem Identified

Neurologic System

No problem identified

Lymphatic/Hematologic System

la namangahubagiyanglu say as verbalized by the SO

No lymhpadenopathy Hematocrit=0.39 Platelet count=36

Risk for bleeding

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Day 2 General Survey: awake, lying on bed, conversant, interact well, cooperative, with patent IVF D5IMB@ 40cc/hr hooked at right metacarpal vein, head is symmetric, no deformities noted in the face, appearance appropriate to age, both upper and lower extremities are symmetric, not in slump posture, weight- 20kg. height- 117cm, arm circumference- 7inches, no signs of distress, afebrile . Areas Assessed Integumentary System Subjective Findings No complaints made Objective Findings Skin uniformly, brownish in color, warm, dry, intact, good skin turgor, no lesions, birthmarks and edema, no rashes noted, hair normally distributed, no clubbing of nails or discolorations, nail beds pink in color and firm w/ prompt capillary refill CRT< 2 sec. HEENT a.Head and face b.Eyes c.Nose e.Oral cavity No complaints made Normocephalic, no lesions and lumps noted, long black hair, no lice noted, no dandruffs noted, Face symmetric, no facial drooling noted, -pupil equally reactive to light and accommodation, pinkish conjunctivae, white sclera, no lesion or redness noted -pinna no mass, lesions, scaling, discharge or tenderness, - nose no deformities, nares patent, no epistaxis noted -mucosa and gingival pink, no lesions, no bleeding of gums -loose upper front teeth, multiple dark spots on most upper teeth, tongue in midline, no lesions Neck supple w/ full ROM, symmetric, no palpable No problem identified lymph nodes, no lump and masses noted, no No problem identified Problem Identified No problem Identified

Neck

No complaints made

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tenderness, no vein distention, palpable carotid pulse, trachea in midline Respiratory System No complaints made Equal chest expansion, no crackles , wheezes, not in respiratory distress, no cough noted, RR-23-30bpm Chest X-ray result reveals: As compared to previous chest film dated 2-11-2012, there is significant decrease in the right pleaural fluid, now small in volume and subpulmonic in location w/ inter-fissural seepage Cardiovascular System dili man sakitakongdughan as verbalized by the pt. No murmurs, apical impulse at 5th ICS in the left MCL, irregular heartbeat noted BP:100/70 PR-82-87 CRT> 2 sec. Breast and Axilla Gastrointestinal System and the abdomen No complaints made Symmetric, no retraction, discharges or lesion, no masses or tenderness, no lymphadenopathy Normoactive bowel sound, 10-12clicks/quadrants, round , soft, non tender, no mass , lesions noted, no abdominal pain as claimed Abdominal girth-22 inch. Oral intake=1400 IV=960cc 27 | P a g e No problem Identified Risk for decrease cardiac Output Risk for impaired Gas exchange

naniwangnasiyakarun,perokusognanasiy anakaon run as verbalized by the SO.

imbalance Nutrition: less than body requirement

BM once moderate in amount, formed, brownish stool Genitourinary/Reproducti ve System daghanrasiyaugnaihi run as verbalized by the pt. Urinated 6x with yellowish color of urine, no foul odor, negative of hematuria Total output=1000cc Musculoskeletal System No complaints of body weakness Full ROM, no limitation of movement, muscle grade 5/5 in both upper and lower extremities, no body weakness noted as claimed, no deformities noted Conversant, oriented to time ,place and person, intact cranial nerves Developmental Stage: -Can count numbers -defines common objects -Obeys triple commands in succession -Knows left and right -Attends first grade -able to solve simple arithmetic -able to spell simple words T-35.5-36.6 0C Lymphatic/Hematologic System No complaints made No lymhpadenopathy Hematocrit=0.39 Platelet count=129 Risk for bleeding No problem Identified No problem identified

Neurologic System

No complaints made

No problem identified

E. DIAGNOSTIC TEST
Diagnostic test/date 28 | P a g e Normal values Result Interpretation Significance Nursing

responsibilities

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2/10/12 CBC & Platelet count

RBC Hematocrit

4-6 x 10 12/L 0.37 0.47

8.06 0.55

Increased Increased

A high RBC count may indicate absolute or relative polycythemia.

Explain the procedure to the patient. Explain to the patient that he may experience a slight discomfort from the tourniquet and the needle puncture. Apply direct pressure to the venipuncture site until the bleeding stops.

Hemoglobin

110 180 g/L

183.0

Increased

WBC

5-10 X 10 9/L

12.7

Increased

High hct&hgb indicates polycythemia or hemoconcentration caused by blood loss & dehydration.

Segmenters

0.50-0.65

0.46

Decreased An increased WBC count commonly signals infection, myocardial infarction.

Lymphocytes

0.25-0.35

0.50

Increased

STABS

0.05-0.10

Normal

Monocytes

0.03-0.07

0.04

Normal

An increased count of lymphocytes can occur in conditions such as influenza & mononucleosis.

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Eosinophils

0.01-0.03

Normal An increased count of platelet can result from hemorrhage, infectious disorders, iron deficiency anemia.

Basophils

0.01

Normal

Platelet count

150

140-450 x 10 9/L

Increased

Diagnostic test/date

Normal values

Result

Interpretation

Significance

Nursing responsibilities

2/11/12 Hematocrit& Platelet count

Hematocrit

0.37-0.47

0.50

Increased

Platelet count

140-450 x 10 9/L

80

Decreased

High hct indicatespolycythemia or hemoconcentration caused by blood loss & dehydration.

2/11/12 Hematocrit 0.37-0.47 0.46 Normal A decreased count can result from aplastic or hypoplastic bone marrow disease, such

Explain to the pt. that the platelet count test determines whether the pt. blood clots normally. Tell the pt. that the test requires a blood sample. Explain who will perform the venipuncture

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Platelet count

140-450 x 10 9/L

55

Decreased

2/11/12 Hematocrit 0.37-0.47 140-450 x 10 9/L Platelet count 0.37-0.47 2/12/12 Hematocrit 140-450 x 10 9/L 39 Platelet count 0.37-0.47 2/13/12 Hematocrit Platelet count 140-450 x 10 9/L 0.39 50 Normal Decreased Decreased 0.37 Normal 0.46 46 Normal Decreased

as leukemia, or disseminated infection, ineffective thrombopoiesis caused by folic acid or vitamin B12 deficiency, pooling of platelets in an enlarged spleen, increased platelet destruction caused by drugs or immune disorders, disseminated intravascular coagulation, mechanical injury to platelets.

and when. Inform the pt. that she need not restrict food and fluids. Explain to the pt. that he may feel slight discomfort from the tourniquet and needle puncture.

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Diagnostic test/date

Normal values

Result

Interpretation

Significance

Nursing responsibilities

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2/11/12 Hematocrit& Platelet count

Hematocrit

0.37-0.47

0.50

Increased

Platelet count

140-450 x 10 9/L

80

Decreased

High hct indicatespolycythemia or hemoconcentration caused by blood loss & dehydration.

2/11/12 Hematocrit 0.37-0.47 0.46 Normal A decreased count can result from aplastic or hypoplastic bone marrow disease, such as leukemia, or disseminated infection, ineffective thrombopoiesis caused by folic acid or vitamin B12 deficiency, pooling of platelets in an enlarged spleen, increased platelet destruction caused by drugs or immune disorders, disseminated

Platelet count

140-450 x 10 9/L

55

Decreased

2/11/12 Hematocrit

0.37-0.47

0.46

Normal

140-450 x 10 9/L Platelet count

46

Decreased

Explain to the pt. that the platelet count test determines whether the pt. blood clots normally. Tell the pt. that the test requires a blood sample. Explain who will perform the venipuncture and when. Inform the pt. that she need not restrict food and fluids. Explain to the pt. that he may feel slight discomfort from the tourniquet and needle puncture.

2/12/12 34 | P a g e

Hematocrit

0.37-0.47

0.37

Normal

Platelet count

140-450 x 10 9/L

39

Decreased

intravascular coagulation, mechanical injury to platelets.

2/13/12 Hematocrit 0.37-0.47 0.39 Normal

Platelet count

140-450 x 10 9/L

50

Decreased

February 11,2012 Chest AP PORT Result: Veil The The The The like haziness seen at the right lung with large ribbon-like homogenous density at the periphery. right hemidiaphragm was partially obscured. trachea is at the midline. heart is normal in size and orientation. bony thorax is normal

Impression: Right Pleural Effusion, moderate in amount. 35 | P a g e

February 13,2012

Chest AP Port

Result:

As compared to previous chest film dated 2-11-12, there is significant decrease in the right pleural fluid, now small in volume and subpulmonic in location with inter-fissural seepage. Hazy pneumonic infiltrates seen in both inner to mid lung zones with right midline and lower lobes atelectasis. Heart and great vessels are not unusual. The right costophrenic sulcus and hemidiaphragm are obscured. The left costophrenic sulcus and hemidiaphragm are intact. No other significant interval chest findings.

2/10/12 PROTIME (PROTHROMBIN TIME) Patient: 20.4 seconds Control: 12.5 seconds Activity: 61.3% INR: 1.88

APTT (Activated Partial Thromboplastin Time) Patient : 48.0 seconds Control: 29.5 second
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VI.

ANATOMY AND PHYSIOLOGY

The Hematologic System The structures of the hematologic or hematopoietic system include the blood, blood vessels, and blood-forming organs (bone marrow, spleen, liver, lymph nodes, and thymus gland). The major function of blood is to carry necessary materials (oxygen, nutrients) to cells and to remove carbon dioxide and metabolic waste products. The hematologic system also plays an important role in hormone transport, the inflammatory and immune responses, temperature regulation, fluid-electrolyte balance, and acid-base balance. Bone Marrow 1. Contained inside all bones, occupies interior of spongy bones and center of long bones; collectively one of the largest organs of the body (4%-5% of total body weight) 2. Primary function is hematopoiesis (the formation of blood cells) 3. Two kinds of bone marrow, red and yellow 1. Red (functioning) marrow 1. Carries out hematopoiesis; production site of erythroid, myeloid, and thrombocytic components of blood; one source of lymphocytes and macrophages 2. Found in ribs, vertebral column, other flat bones 2. Yellow marrow: red marrow that has changed to fat; found in long bones; does not contribute to hematopoiesis 4. All blood cells start as stem cells in the bone marrow; these mature into the different, specific types of cells, collectively referred to as formed elements of blood or blood components: erythrocytes, leukocytes, and thrombocytes.

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Blood 1. Composed of plasma (55%) and cellular components (45%) 2. Hematocrit 1. Reflects portion of blood composed of red blood cells 2. Centrifugation of blood results in separation into top layer of plasma, middle layer of leukocytes and platelets, and bottom layer of erythrocytes. 3. Majority of formed elements is erythrocytes; volume of leukocytes and platelets is negligible. 3. Distribution 1. 1300 ml in pulmonary circulation 1. 400 ml arterial 2. 60 ml capillary 3. 840 ml venous 2. 3000 ml in systemic circulation 1. 550 ml arterial 2. 300 ml capillary 3. 2150 ml venous Plasma 1. Liquid part of blood; yellow in color because of pigments 2. Consists of serum (liquid portion of plasma) and fibrinogen 3. Contains plasma proteins such as albumin, serum globulins, fibrinogen, prothrombin, plasminogen 1. Albumin: largest of plasma proteins, involved in regulation of intravascular plasma volume and maintenance of osmotic pressure 2. Serum globulins: alpha, beta, gamma 1. Alpha: role in transport of steroids, lipids, bilirubin 2. Beta: role in transport of iron and copper 3. Gamma: role in immune response, function of antibodies 3. Fibrinogen, prothrombin, plasminogen (see Coagulation) Cellular Components
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Cellular components or formed elements of blood are erythrocytes (red blood cells [RBCs]), which are responsible for oxygen transport; leukocytes (white blood cells [WBCs]), which play a major role in defense against microorganisms; and thrombocytes (platelets), which function in hemostasis. 1. Erythrocytes 1. Bioconcave disc shape, no nucleus, chiefly sacs of hemoglobin 2. Cell membrane is highly diffusible to O2 and CO2 3. RBCs are responsible for oxygen transport via hemoglobin (Hgb) 1. Two portions: iron carried on heme portion; second portion is protein 2. Normal blood contains 12-18 g Hgb/100 ml blood; higher (14-18 g) in men than in women (12-14 g) 4. Production 1. Start in bone marrow as stem cells, released as reticulocytes (immature cells), mature into erythrocytes 2. Erythropoietin stimulates differentiation; produced by kidneys and stimulated by hypoxia 3. Iron, vitamin B12, folic acid, pyridoxine (vitamin B6), and other factors required for erythropoiesis 1. Hemolysis (destruction) 1. Average life span 120 days 2. Immature RBCs destroyed in either bone marrow or other reticuloendothelial organs (blood, connective tissue, spleen, liver, lungs, and lymph nodes) 3. Mature cells removed chiefly by liver and spleen 4. Bilirubin: byproduct of Hgb released when RBCs destroyed, excreted in bile 5. Iron: freed from Hgb during bilirubin formation; transported to bone marrow via transferrin and reclaimed for new Hgb production 6. Premature destruction: may be caused by RBC membrane abnormalities, Hgb abnormalities, extrinsic physical factors (such as the enzyme defects found in G6PD) 7. Normal age RBCs may be destroyed by gross damage as in trauma or extravascular hemolysis (in spleen, liver, bone marrow)

1. Leukocytes: granulocytes and mononuclear cells: involved in protection from bacteria and other foreign substances 1. Granulocytes: eosinophils, basophils, and neutrophils 1. Eosinophils: involved in phagocytosis and allergic reactions 2. Basophils: involved in prevention of clotting in microcirculation and allergic reactions
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3. Eosinophils and basophils are reservoirs of histamine, serotonin, and heparin 4. Neutrophils: involved in short-term phagocytosis 1. mature neutrophils: polymorphonuclear leukocytes 2. immature neutrophils: band cells (bacterial infection usually produces increased numbers of band cells) 1. Mononuclear cells: monocytes and lymphocytes: large nucleated cells 1. Monocytes: involved in long-term phagocytosis; play a role in immune response 1. largest leukocyte 2. produced by bone marrow: give rise to histiocytes (Kupffer cells of liver), macrophages, and other components of reticuloendothelial system 1. Lymphocytes: immune cells; produce substances against foreign cells; produced primarily in lymph tissue (B cells) and thymus (T cells) (see also Immune Response)

1. Thrombocytes (platelets) 1. 2. 3. 4. Fragments of megakaryocytes formed in bone marrow Production regulated by thrombopoietin Essential factor in coagulation via adhesion, aggregation, and plug formation Release substances involved in coagulation

Blood Groups 1. Erythrocytes carry antigens, which determine the different blood groups. 2. Blood-typing systems are based on the many possible antigens, but the most important are the antigens of the ABO and Rh blood groups because they are most likely to be involved in transfusion reactions. 1. ABO typing 1. Antigens of system are labelled A and B. 2. Absence of both antigens results in type O blood.
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Presence of both antigens is type AB. Presence of either A or B results in type A and type B respectively. Nearly half the population is type O, the universal donor. Antibodies are automatically formed against the ABO antigens not on person's own RBCs; transfusion with mismatched or incompatible blood results in a transfusion reaction (Table 4.17). 2. Rh typing 1. Identifies presence or absence of Rh antigen (Rh positive or Rh negative). 2. Anti-Rh antibodies not automatically formed in Rh-negative person, but if Rh-positive blood is given, antibody formation starts and a second exposure to Rh antigen will trigger a transfusion reaction. 3. Important for Rh-negative woman carrying Rh-positive baby; first pregnancy not affected, but in a subsequent pregnancy with an Rhpositive baby, mother's antibodies attack baby's RBCs ( in Unit 6). Blood Coagulation Conversion of fluid blood into a solid clot to reduce blood loss when blood vessels are ruptured. 1. Systems that initiate clotting 1. Intrinsic system: initiated by contact activation following endothelial injury ("intrinsic" to vessel itself) 1. Factor XII initiates as contact made between damaged vessel and plasma protein 2. Factors VIII, IX, and XI activated 2. Extrinsic system 1. Initiated by tissue thromboplastins, released from injured vessels ("extrinsic" to vessel) 2. Factor VII activated 1. Common pathway: activated by either intrinsic or extrinsic pathways 1. Platelet factor 3 (PF3) and calcium react with factors X and V. 2. Prothrombin converted to thrombin via thromboplastin. 3. Thrombin acts on fibrinogen, forming soluble fibrin. 4. Soluble fibrin polymerized by factor XIII to produce a stable, insoluble fibrin clot. 1. Clot resolution: takes place via fibrinolytic system by plasmin and proteolytic enzymes; clot dissolves as tissue repairs.

3. 4. 5. 6.

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Spleen 1. Largest lymphatic organ: functions as blood filtration system and reservoir 2. Vascular, bean shaped; lies beneath the diaphragm, behind and to the left of the stomach; composed of a fibrous tissue capsule surrounding a network of fiber 3. Contains two types of pulp 1. Red pulp: located between the fibrous strands, composed of RBCs, WBCs, and macrophages 2. White pulp: scattered throughout the red pulp, produces lymphocytes and sequesters lymphocytes, macrophages, and antigens 4. 1%-2% of red cell mass or 200 ml blood/minute stored in spleen; blood comes via the splenic artery to the pulp for cleansing, then passes into splenic venules that are lined with phagocytic cells, and finally to the splenic vein to the liver. 5. Important hematopoietic site in fetus; postnatally produces lymphocytes and monocytes 6. Important in phagocytosis; removes misshapen erythrocytes, unwanted parts of erythrocytes 7. Also involved in antibody production by plasma cells and iron metabolism (iron released from Hgb portion of destroyed erythrocytes returned to bone marrow) 8. In the adult, functions of the spleen can be taken over by the reticuloendothelial system. Liver 1. Involved in bile production (via erythrocyte destruction and bilirubin production) and erythropoiesis (during fetal life and when bone marrow production is insufficient). 2. Kupffer cells of liver have reticuloendothelial function as histiocytes; phagocytic activity and iron storage. 3. Liver also involved in synthesis of clotting factors, synthesis of antithrombins. The Circulatory System The Circulatory System is designed to deliver oxygen and nutrients to all parts of the body and pick up waste materials and toxins for elimination. This system is made up of the heart, the veins, the arteries, and the capillaries. Circulation is achieved by a continuous one-way movement of blood throughout the body. The network of blood vessels that flow through the body is so extensive that blood flows within close
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proximity to almost every cell. Heart The heart is a muscular pump that propels blood throughout the body. The heart is located between the lungs, slightly to the left of center in the chest. The heart is broken down into four chambers including:

The right atrium, which is a chamber which receives oxygen- poor blood from the veins. The right ventricle which pumps the oxygen-poor blood from the right atrium to the lungs. The left atrium which receives the now oxygen-rich blood that is returning from the lungs. The left ventricle, which pumps the oxygenated blood through the arteries to the rest of the body.

This process occurs about 72 times per minute, every day of our lives. Blood Vessels Blood vessels are broken down into three groups: the arteries which carry blood out of the heart to the capillaries, the veins which transport oxygen-poor blood back to the heart, and the capillaries which transfer oxygen and other nutrients into the cells and removes carbon dioxide and other metabolic waste from these body tissues. Blood Pressure Blood pressure is the force exerted by the blood against the walls of the blood vessels. The output or direct pumping of the heart and the resistance to blood flow in the vessels determines blood pressure. Resistance is determined by blood viscosity and by friction between the blood and the wall of the blood vessel. Blood pressure = blood flow x resistance.

The Immune System The immune system is part of our general body defenses against disease. It functions by recognizing viruses and bacteria and converting that information into hormones that activate the immune process. This response can be both specific, where the body responds only to certain agents and no others as well as nonspecific, where the body works to defend
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itself any harmful agent that enters the body. Immunity is the ability of an individual to resist or overcome the effects of a particular disease or other harmful agent. Immunity, however, is a selective process, with one being immune to one disease and not necessarily another. Immunity can be either inborn, which is due to inherited factors, or acquired. Acquired immunity develops during one's lifetime as they encounter various harmful agents and successfully fight them off. Acquired immunity is easily seen in the case that we only get the chicken pox once as a child, even though we may be exposed to them on a number of occasions. The immune system has been broken down into a number of different "lines of defenses", starting simply with mechanical barriers and then becoming more and more complex, they include:

Mechanical barriers - are the first line of defense against harmful agents. Mechanical barriers include the skin, mucus membranes that line passageways that enter the body. Chemical Barriers - tears, perspiration and saliva work to wash away harmful invaders while digestive juices and enzymes destroy bacteria and other toxins from ingested substances. Phagocytosis - is the ability of certain white blood cells to take in and destroy waste and foreign materials. Natural Killer Cells - are able to distinguish cells with an abnormal cellular membrane such as tumor cells or cells infected with a virus and kill them on contact. Inflammation - is the body's effort to get rid of anything that irritates it. If the inflammation is due to pathogens, the inflammation is referred to as an infection. Fever - boosts the immune system by stimulating phagocytes, increasing metabolism and decreasing the ability of certain organisms to multiply. Cellular Immunity: T cells kill infected cells in the cell-mediated response. Once inside cells, pathogens are harder to detect. Cell-mediated immunity recognizes and kills the bodys own infected cells. B-cells: Develop in the bone marrow and become antibody-producing plasma cells. Bind antigens to surfacebound antibodies. T-cells: Develop in the thymus; differentiate into T-helper cells or T-cytotoxic cells.Antibodies: Antibodies are soluble proteins that are bound to the surface of cells, as well as unbound in the circulation. There are 5 types (isotypes) of antibodies: IgA: protects mucosal surfaces, IgD: B-Cell antigen receptor, IgE: involved in allergy, IgG: majority of antibody-based immunity and IgM: key to B-Cell immunity.

The Lymph System All body tissues live in a liquid environment, both in the cells and surrounding them. During cellular metabolism, waste
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products, including carbon dioxide and other substances are routed back through the blood stream to be eliminated. In addition to the elimination provided for by the circulatory system, a second pathway for the removal of tissue fluids from the body is achieved though the lymph system. The function of the lymph system is to remove excess tissue fluids that do not return through the circulatory system. In addition, the lymph system is responsible for absorbing protein form this fluid and returning it to the blood. Like the circulatory system, the lymphatic system is made up of a series of capillaries and lymphatic vessels. Unlike the circulatory system, the lymph system does not have a heart to propel lymph (tissue fluids that have entered the lymphatic system) through the system. The movement of lymph is based upon either the volume of fluid within the lymph vessel or by mechanical means, i.e. through movement of the skeletal muscles, where the muscles compress the lymphatic vessels and drive the lymph forward. Throughout the lymph system, can be found a series of lymph nodes, whose function it is to filter the lymph, trapping and destroying bacteria and other foreign particles. Lymph nodes can be found throughout the body, but tend to be grouped together. Major groupings of lymph nodes can be found in the neck (cervical nodes), in the armpits (axillary nodes), near the trachea and bronchial tubes (tracheobronchial nodes), in and around the intestines (mesenteric nodes) and in the groin area (Inguinal nodes). Thymus The thymus gland is the site in which T-lymphocytes develop and mature before birth and is most active prior to puberty. The thymus secretes the hormone thymosin, which promotes the growth of lymphocytes and lymphoid tissue throughout the body. Tonsils The tonsils, once thought of as a useless organ, are actually masses of lymphoid tissue that are designed to filter tissue fluids. Spleen The spleen is an organ that contains lymphoid tissue and is designed to filter blood. It is located in the upper left quadrant of the abdominal cavity and is protected by the ribs. One function of the spleen is to filter out old red blood cells. The spleen also harbors phagocytes, which engulf bacteria and other foreign particles. The spleen also serves as a reservoir of blood in cases of emergency. Vermiform appendix Although the function of the vermiform appendix is unknown, the appendix is rich in lymph tissues. The appendix is located at the end of the cecum, which is part of the large intestine.

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VII.RISK FACTORS AND PATHOPHYSIOLOGY (CONCEPTMAP)

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VIII. NURSING MANAGEMENT


A. NCP
NURSING CARE PLANS Problem Identified: decrease platelet count Nursing Diagnosis: Risk for bleeding r/t altered clotting factor 20 DHF Cause Analysis(w/ reference):Blood platelets also known as thrombocytes play an important role in your body. These cell fragments are natural source of growth and
play basic role in process of hemostasis (preventing bleeding from damaged blood vessel) as well. When vascular endothelial cell that are infected with dengue virus gets combined with platelets they tend to destroy platelets. This is one of the major causes of low platelet count in dengue fever.( http://www.onlymyhealth.com/cause-lowplatelet-count-in-dengue-fever-)

Cues
Subjective: 47 | P a g e

Objectives
STO:

Nursing Interventions
Independent:

Rationale

Evaluation

La ramangadugoiyangilong, brown rapudang color saiyang tae as verbalized by the S.O Objective: -Plalete lab. Result-36 -brownish color stool -BP 100/80 -PR-87

Within 2 hrs. of nursing intervention and health teaching the pt. will be able gain information about the diseases process and its potential problem. LTO: Within 2 days of nursing care the pt. will be able to demonstrate behaviors and ways that reduces risk for bleeding.

1. Assessed for signs and symptoms of G.I bleeding. Check for secretions.Observe color and consistency of stool or vomitous. 2. Observed for the presence of petechiae, ecchymosis, bleeding from one or more sites. 3.Monitor pulse, BP 4.Noted changes in of mentation and level of conciousnes 5. Instructed the pt. to avoid sharp object. 6. Checked pt.every 2 hrs. 7.Keep bed in low position at aleast 300 8.Keep the pts. free from clutter 9.Assist pt. w/ transfer, ambulation 10.Recommend avoidance of aspirin containing products 11. Emphasize the importance of safety measures.

STO:
1. The G.I tract is the most usual source of bleeding of its mucosal fagility. 2. Sub acute disseminated intravascular coagulation may develop secondary to altered clotting factors. 3. an increase in pulse w/ decreased blood pressure can indicate loss of circulating blood volume. 4. Change may indicate cerebral perfusion secondary to hypovolemia, hypoxemia 5. To avoid injury or skin breakdown. 6. This is the primary preventive measure to ensure pts. safety. 7. To reduce risk factor for injury. 8. To promote individual safety. 9. To avoid and preventing from tripping from bed to the floor. 10. Prolongs coagulation potentiating risk for hemorrhage. 11. This promotes education and increases the awareness of clients condition. Met- pt was able to verbalized understanding on the disease process and enumerates potential problems.

LTO: Met- pt was able to enumerate and keep in mind the ways that reduces risk for bleeding as evidenced by verbalization of 4 or 5 ways to reduce risk for bleeding.

NURSING CARE PLANS Problem Identified: weight loss Nursing Diagnosis: Imbalanced Nutrition: less than body requirements r/t increased metabolic demand and decrease oral intake 20 Dengue Hemorrhagic Fever Stage 3 Cause Analysis(w/ reference):There is an alteration in nutrient requirements that results from illness , since there is an increase need for calories, and decrease food
intake .(Fundamentals of Nursing by Tallor and Lilis 5th ed.p.1251)

Cues

Objectives

Nursing Interventions

Rationale

Evaluation

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Subjective: karun pa gyudnibalikganaiyangkaon,walanasiyaykaonkanonsukadna admit nasiya as verbalized by the S.O Objective: -normally BMI: 14.6 - significant weight loss (25kg to 20 kg) - arm circumference: 6 inches - observable loss of appetite

STO: Within 2hrs. of emphasizing the importance of food intake the pt. will be able to increase adequate diet for age. LTO: Within 2 days of independent nursing intervention and w/ the pt.s and S.O cooperation, the pt. will be able to achieve adequate nutrition as evidenced by progression of wt. gain

Independent: 1. Determined the childs current nutritional status using age-appropriate measurement, including wt. and body build, strength, activity level, sleep and rest cycle. 2. Elicited information from the child/parents of the child regarding typical daily food intake, determining food and beverages normally consumed. Discussed eating habits and food preferences. 3. Determined psychologic, cultural/religious desires/influences and dietary choices. 4. Auscultated bowel sound. Note the characteristic of stool. 5. Discussed what type of candy parents, others sweets, snacks, and sodas child eats/drinks. 6. Emphasized the importance of well-balanced, nutritious intake. Provided information regarding on the individual nutritional needs and ways to make these needs within financial constraints. Avoid arguing over food intake. Provide food without comment. 7. Reviewed drug regimen, side effects, and potential interactions with other medications/ OTC drugs/ herbs.

STO:
1. Identifies individual nutritional needs, and provides comparative baseline. 2. Baseline information to determine adequacy of intake. Knowledge of childs specific likes and dislikes maybe helpful in meeting nutritional needs during the time when appetite is suppress or child has no interest in food. 3. Dietary beliefs, such a vegetarianism, can affect nutritional intake. Usual ethnic food choices can improve a childs intake when appetite is poor. 4. Provides information about digestion/ bowel fxn and may affect choice/timing of feeding. Met- pt. was able to increased oral intake.

LTO: Met- pt. was able to achieved adequate nutrition as evidenced by increased wt. gain and verbalization of S.O about the progression of the pt.s condition

5. Identifies what childs eat in a typical day. Provides opportunity for identifying teaching needs and providing healthy snacks.
6. Although nutritious intake is important, arguing over food is counter-productive. Providing age-appropriate guidelines to children as well as to parents/care provider may help them in making healthy choices. 7. Timing of medical doses, interactions with certain foods

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8. Clarified family/caregiver access to/ use f resources such as food stamp, budget counseling and other appropriate assistance program. Collaborative: 9. Established a nutritional plan that meets individual needs, incorporating specific food restrictions, special dietary needs. Referred to dietitian/ nutritional team. 10. Reviewed lab results.

can alter the effects of medication/digestion/ absorption of nutrients.

8. Maybe necessary to improve childs intake and availability of food to meet nutritional needs. 9. Corrects/control underlying contributing factors. 10. Indicators of nutritional health and effects of nutrients and organ fxn.
.

NURSING CARE PLANS


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Problem Identified: Irregular heart beat Nursing Diagnosis: Risk for decrease cardiac output r/t altered myocardial contractility and rhythm secondary to DHF Cause Analysis(w/ reference):Dengue fever may adversely affect cardiac function. An echocardiographic showed depressed myocardial contractility and suboptimal
heart rate response in some patients with dengue hemorrhagic fever. Acute reversible hypokinesia and reduction in left ventricular ejection fraction was also reported by . The underlying mechanisms were postulated to be immune in origin, although myocarditis may be a contributory factor. Fever production in response to exogenous pyrogens is believed to be mediated mostly by cytokine prostaglandin pathways, and neural input is important in the early phases of fever . Concentrations of cytokines, including tumor necrosis factor, interferon- , interleukin-8 (IL-8), IL-10, and IL-12, are substantially increased during dengue infection. Their levels likely correlate with specific clinical manifestations and illness severity . The relationship of cytokines to relative bradycardia is unknown. Further studies could consider the relative importance of immune and neural mechanisms and also any direct cardiac pathology in the etiology of dengue-associated relative bradycardia. (Guzman MG, Kouri G. Dengue: an update.Lancet Infect Dis. 2002;2:3342www.pubmed. com. )

Cues
Subjective: no verbal cues Objective: Presence of abnormal heart sound HR- 87bpm ECG reveals: prob. LVH BP- 100/80mmHG CRT <2secs

Objectives
STO: Within 8h of nursing intervention pt. will be able to maintain normal vital signs.

Nursing Interventions
Independent: 1. Monitored BP. 2. Evaluated the quality and equality of pulses as indicated. 3. Auscultated heart sounds. Note development of S3/S4, presence of murmur/rubs. 4. Monitored heart rate and rhythm. Documented dysrrhythmias. 5. Noted response to activity and promote rest appropriately. 6. Provided small/easily digested meals. Limit caffeine intake eg., chocolate, coffee, cola as indicated. Collaborative: 7. Have emergency equipment/medication available. 8. Administer supplemental oxygen as indicated. 9. Review ECG, chest XRAY

Rationale
1. Hypotension may occur r/t ventricular dysfxn, hypoperfusion of the myocardium and vagal stimulation. 2. Decrease cardiac output in diminished, weak/thread pulses. Irregularities suggest dysrrhythmias which may require further evaluation and monitoring,. 3. S3 is usually assoc. with heart failure, but may also noted with the mitrial insufficiency and left ventricular overload that accompany severe infarction. S4 may assoc in myocardial ischemia, ventricular stiffening, and pulmonary or systemic hypertension. Murmurs indicate disturbances of normal blood flow. 4. Heart rate and rhythm respond to meds., activity, and developing complications. 5. Over exertion increase oxygen consumption/demand and can

Evaluation
STO: Met- pt was able to maintained normal vital signs. LTO: Unmet- pt. exhibits irregular heart beat

LTO: Within 2 days of giving nursing interventions and collaborative mgt. pt. will be able to achieved normal hemodynamic stability as evidenced by decrease frequency/absence of dysrrhythmias

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result. 10. Refer to cardiologist

compromise myocardial fxn. 6. Large meal may increase myocardial workload and may cause vagal stimulation. Caffeine is a direct cardiac stimulant that can increase heart rate. 7. Sudden coronary occlusion, lethal dysrhythmias, extension of infarct, and unrelenting pain are situations that may precipitate cardiac arrest, requiring immediate life-threatening therapies. 8. Increases amount of oxygen available for myocardial uptake reducing cellular dysrhythmias 9. Provide information regarding status of ventricular fxn/electrolyte balance and effects of drug therapies. Chest Xray may reflect pulmonary edema r/t ventricular dysfxn. 10. For further management and evaluation.

NURSING CARE PLANS Problem Identified: Plueral effusion Nursing Diagnosis: Risk for impaired gas exchange r/t pleural effusion 20 DHF Cause Analysis(w/ reference):Impaired gas exchange is a state in which there is excess or deficit oxygenation and carbon dioxide elimination. The
compensatory mechanism of lungs is to lose effectiveness of its defense mechanisms and allow organisms to penetrate the sterile lower respiratory tract where inflammation develops. Disruption of mechanical defenses and ciliary motility leads to colonization of lungs and subsequent infection. Inflamed and fluid-filled alveolar sacs cannot exchange oxygen and carbon dioxide effectively. The release of endotoxins by the microbes can lodge in the brain, affecting the respiratory center in medulla resulting to altered oxygen supply. 52 | P a g e

Cues

Objectives

Nursing Interventions
Independent:

Rationale

Evaluation STO:
PARTIALLY METPt.s RR-23

Subjective: STO: La ramanpudbiyanasiyanangluspad Within 8 hrs. of as verbalized by the S.O providing nursing care and Objective: collaborative management the -Chest X-ray : pt. will be able to stabilized normal As compared to previous chest RR from 30 to 20bpm. film dated 2-11-2012, there is significant decrease in the right pleaural fluid, now small in LTO: volume and subpulmonic in location -w/ inter-fissural Within 2 days of seepage effective nursing intervention and -RR =30 collaborative management the -CRT< 2 sec. pt. was free cyanosis and -O2 98% ineffective ventilation.

1. Established rapport- Monitor and record vital signs 2. Monitored respiratory rate, depth and rhythm 3. Assessed pts general condition 4. Auscultated breath sounds, note areas of decreased/adventitious breath sounds as well as fremitus 5. Elevated head of the pt. 6. Note for presence of cyanosis 7. Encouraged frequent position changes and deep-breathing exercises 8. Provided health teaching on how to alleviate pts condition 9. Provided supplemental oxygen at lowest concentration indicated by laboratory results and client symptoms/ situation 10. Reviewed laboratory result. 11. Administered prescribed medications as ordered: Furosemide 10mg IVTT

1. To gain pt./SOs trust and cooperation- To obtain baseline data 2. To assess for rapid or shallow respiration that occur because of hypoxemia and stress 3. To note for etiology precipitating factors that can lead to impaired gas exchange. 4. To evaluate degree of compromise 5. To enhance lung expansion 6. To assess inadequate systemic oxygenation or hypoxemia. 7. To promote optimum chest expansion 8. To correct/ improve existing deficiencies 9. To determine pts oxygenation status 10. To empower SO and pt 11. For the pharmacological management of the patients condition

LTO: MET Pt. was free from cyanosis and ineffective ventilation.

NURSING CARE PLANS


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Problem Identified: pleural effusion Nursing Diagnosis: Risk for Infection r/t fluid accumulation in the pleural cavity 20 DHF Cause Analysis: The primary symptoms of DHF consist of plasma leakage and bleeding, which are potentially lethal, as plasma leakage is caused by an increase of capillary permeability, often resulting in hemoconcentration, pleural effusions and ascites; and bleeding, caused by capillary fragility and thrombocytopenia (a marked decrease of platelets) may result in bleeding incidents into the skin (petechial skin hemorrhages), or even life-threatening bleeding into the gastrointestinal tract. ( http://www.medicinemd.com/Med_articles/Dengue_fever_en.html) CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective:

STO: Within 3-4 hours of giving effective nursing interventions and health teachings to the pt/SO, pt will be identify different interventions to prevent or reduce the risk of infection

Independent: 1. Reviewed pathology of the condition- risk for infection, and possible dissemination of infection through bronchi to adjacent tissues or via bloodstream and lymphatic systemand potential spread of infection via airborne during coughing, sneezing, spitting, talking, laughing and singing. 2. Identified others for potential carrier, such as household members, playmates, and friends. 3. Reviewed proper disposal of tissue and good hand-washing. request return demonstration. 4. Monitored temperature as indicated. 5. Encouraged selection and ingestion of well-balanced meals. Provide frequent small snacks in place for large meals as appropriate. 6. Assessed SO/patients knowledge and ability to maintain opportunistic infection prophylactic regimen. 7. Washed hands before and after all care contacts. Instruct pt./SO to wash 1. Helps client to realize and accept the necessity in adhering to medication regimen to prevent infection and its complications. 2. Other family member or friends of the client who has a current infection (any other form), must require a course prevention of requiring infections. 3. Behaviors necessary to prevent occurrence of infection. 4. Febrile reactions are indicators of presence of infection. 5. Presence of anorexia or preexisting malnutrition lowers resistance to infection and impairs healing process. Small snacks may enhance overall intake. 6. Multiple medication regimen is difficult to maintain over a long period of time. Patient may adjust medication regimen based on side effects experienced, contributing to inadequate prophylaxis, active disease, and resistance. 7. Reduces the risk of acquiring

STO: MET Pt./S.O was able to identify different interventions to prevent or reduce the risk of infection.

No verbal cues

Objectives:

Chest X-ray : As compared to previous chest film dated 2-112012, there is significant decrease in the right pleaural fluid, now small in volume and subpulmonic in location -w/ inter-fissural seepage -RR =30 -CRT< 2 sec. 54 | P a g e

LTO: Within 1-2 days of giving effective nursing interventions and health teachings to the pt/SO, pt will be able to demonstrate techniques and initiate lifestyle changes to promote

LTO: The pt/S.O. was able to demonstrate techniques and initiate lifestyle changes to promote safe environment and was free from signs of

-O2 98% -T.35.6 0C

safe environment.

hands as indicated. 8. Provided a clean, well-ventilated environment. 9. Assessed respiratory rate/ depth; note dry spasmodic cough on inspiration, presence of sputum and presence of wheezes or ronchi. Collaborative:

infection and cross-contamination. 8. Reduces the number of pathogens presented to the immune system and reduces possibility of pt. contracting nosocomial infection. 9. Respiratory congestion/ distress may indicate developing Pleural Effusion. 10. Shifts in the differential and changes in WBC count indicate infectious process. 11. Bacteriacidal

infection.

10. Monitored lab studies, e.g., CB, CX-ray 11. Administered medication as indicated : CEFUROXIME Reference: : Nursing Diagnosis Handbook by: Judith M. Wilkinson

NURSING CARE PLANS


Problem Identified: less knowledge Nursing Diagnosis: Deficient Knowledge related to potential risks of Dengue Hemorrhagic Fever Cause Analysis: Dengue vector control requires effective participation of the local community.Although education campaigns have increased peoples awareness of dengue, it remains unclear to what extent this knowledge is put into practice, and to what extent this practice actually reduces mosquito populations,public has less knowledge about dengue hemorrhagic fever, a fatal complication, than dengue fever. ( http://www.ajtmh.org/content/74/4/692.) CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective:

STO:

Independent: 1. Ba aware of and deal with anxiety of client and family. 2. Provided activity role for the client/SO in 1. Anxiety can interfere with ability to hear and assimilate information. 2. Learning is enhanced when persons STO:

Patient/S.O may 55 | P a g e

Within 3-4 hours of giving

verbalize statements of concerns and questions regarding the condition.

Objectives: Statements of concerns and questions Inaccurate follow-through of instructions Frequent asking questions regarding the disease.

health teachings regarding present condition, the patient/mother will be able to verbalize understanding of own condition/disease process, prognosis and potential complications.

LTO:

Within 1-2 days of giving health teachings to the patient/mother, she will be able to identify/initiate necessary practices/lifestyle changes to for dengue-free environment

the learning process. 3. Provided written and verbal information as indicated. Include articles of books, internet sites, special TV programs related to client/family needs and encourage reading and discussing what they learn. 4. Paced learning activity to individual needs. 5. Reviewed condition and prognosis/ future expectations. 6. Discussed relationship of drug use to current situation. 7. Educated about the different practices to eradicate/lessen mosquitoes carrying dengue virus. 8. Discussed potential for re-occurrence of the disease if bitten again with mosquitoe carrying dengue virus with another strand of DNA 9. Informed client/S.O alternative ways on treating/minimizing complications of DHF 10. Discussed variety of helpful organizations and community programs that are available for assistance/referral.

are actively involved. 3. Helps client/SO make informed choices about future and can be a useful addition to other therapeutic approaches. 4. Assist in planning for long-range changes necessary for maintaining sobriety/dengue-free status. 5. Facilitates learning because information is more readily assimilated when timing is considered. 6. Provides knowledge base from which client can make informed choices. 7. Often client has misinterpretation of real reason for admission to the medical setting. 8. Information will help client understand possible re-occurrence of such condition. 9. Even though cure may have passed, client maybe at risk of developing the same condition. 10. Long-term support is necessary to maintain optimal recovery. Community programs maybe helpful on eradicating/minimizing mosquitoes carrying dengue virus.

MET The S.Owas able to verbalized understanding the condition and disease process of the pt.

LTO: MET The S.O was able to identify/initiate necessary practices/lifestyle changes to for dengue-free environment.

Reference: : Nursing Diagnosis Handbook by: Judith M. Wilkinso

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B. HEALTH EDUCATION PLAN


Objectives: 1) Within 1 hour of health teachings, the client and SO will verbalize understanding about the goals of treatment. 2) Within 1 hour of health teachings, the client and SO will verbalize understanding of therapeutic needs of the pts condition. 3) Within 1 hour of health teachings, the client and SO will verbalize the importance of proper hygiene in maintaining good health. Materials Needed: 1) Visual aids 2) Pamphlets/ fact sheets GENERAL HEALTH TEACHING SPECIFIC HEALTH TEACHING

Medication

Diet

Advice client and SO to take the medication at regular basis. Teach the patient and SO the time , route , dosage ,adverse effect, and special consideration of each medications.

Proper Hygiene

Drinking extra glasses of water a day and eating less salt. Eating more fruits, vegetables, and low-fat dairy foods Educate the SO about the importance of proper hygiene of the patient from head to toe.

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Rest & Sleep

Cleaning the whole body with tap water every day Educate the SO and patient about the importance of complete bed rest

Safety Precaution Psychological Support Spiritual Support Encouraged the relatives to pray over for the patient and do some reading about bible or God. Provide emotional and spiritual support to patient/families. Observe for symptoms of depression and intervene ASAP Assist family in providing emotional support Instruct the SO to monitor the clients safety everyday to avoid injury from falls. Inform the family of the patient to monitor if there is any sudden change to the patient and report immediately.

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C. DISCHARGE PLAN (METHODS)

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Medication: Vita syrup once a day 7.5 ml Environment: 1. Eliminate Vector by: Changing water and scrubbing sides of lower vases once a week Destroy breeding places of mosquito by cleaning surroundings Proper disposal of rubber tires, empty bottles and cans. Keep water container covered.

2.Avoid too many hanging clothes inside the house 3.Residual spraying with insecticides Treatments: Increase fluid intake CBR for 2 weeks

Health Knowledge of the Disease: SO has been educated that DHF is an acute febrile diseases. It can lead to fatality if not treated immediately. And refer to nearest hospital if she exhibit symptoms of sudden increase of fever and gradually lowering temp, severe abdominal pain and vomiting. Outpatient/Inpatient Referral: The SO instructed to: Diet: Diet for age:
60 P a g e | Encourage intake of foods high in folic acid (e.g. cooked green leafy vegetables, asparagus, and organ meats) as allowed.

Follow up ECG after 1week Follow up check-up after 1 week to Dr.RizaCanoy for further assessment of the pt.

Low fat, low fiber, non-irritating, non-carbonated Noodle soup may be given.

IX.
GENERIC NAME AND TRADE NAME

MEDICAL MANAGEMENT
CLASSIFICATI ON MECHANISM OF ACTION INDICATION DOSAGE/RO UTE/ FREQUENCY ADVERSE EFFECT NURSING RESPONSIBILITIES

GENERIC NAME: CEFUROXIME

Anti-infective Second generation cephalosporin

TRADE NAME: Pharmacef

Interferes with bacterial cell wall synthesis and division by binding to cell wall, causing cell to die. Active against gramnegative and grampositive bacteria, with expanded activity against gram negative bacteria. Exhibits minimal immunosuppressant activity.

Moderate to severe infections, including those of skin, bone, joints, urinary or respiratory tract and septicaemia.

500mg q 8h IVTT

CNS: headache, hyperactivity, hypertonia, seizures GI: nausea, vomiting, diarrhea, abdominal pain, dyspepsia GU: hematuria, vaginal candidiasis, renal dysfunction, acute renal failure Hematologic: haemolytic anemia, aplastic anemia, haemorrhage Hepatic: hepatic

Advise pt. to immediately report rash or bleeding tendency. Teach pt. how to recognize signs and symptoms or superinfection. Instruct the SO to report these right away. Advise pt. to report CNS changes. As appropriate, review all other significant and life threatening

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dysfunction. Metabolic: hyperglycemia Skin: toxic epidermal necrolysis. Other: allergic reaction, drug fever, superinfection, anaphylaxis.

adverse reactions & interactions, especially those related drugs, test, and foods.

GENERIC NAME AND TRADE NAME

CLASSIFI CATION

MECHANISM OF ACTION

INDICATION

DOSAGE/RO UTE/ FREQUENCY

ADVERSE EFFECT

NURSING RESPONSIBILITIE S

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GENERIC NAME: RANITIDINE

Antiulcers H2 Receptors antagonis t

TRADE NAME: Zantac

Reduces gastric acid secretion and increases gastric mucus and bicarbonate production, creating a protective coating on gastric mucosa.

Active duodenal and gastric ulcers, to maintain healing of duodenal and gastric ulcers.

20mg q 8hr IVTT

CNS: Headache, agitation, anxiety GI: nausea, vomiting, diarrhea, constipation, abdominal discomfort or pain. Hematologic: reversible granulocytopenia and thrombocytopenia Hepatic: hepatitis Skin: rash Other: pain at I.M. injection site, burning or itching at I.V. site, hypersensitivity reaction.

Assess vital signs. Monitor CBC liver function tests. Caution pt. to avoid hazardous activities until she knows how drug affects concentration and alertness.

GENERIC NAME AND TRADE NAME

CLASSIFICATIO N

MECHANISM OF ACTION

INDICATIO N

DOSAGE/RO UTE/ FREQUENCY

ADVERSE EFFECT

NURSING RESPONSIBILITIES

GENERIC NAME: PARACETAMOL 63 | P a g e

Analgesic Anti-pyretic

-Decreases fever by inhibiting the effects of pyrogens on the

Relief of mild-tomoderate pain

250mg 5ml q 4h p.o.prn for fever

CNS: weakness, fatigue, nervousness, sedation,drowsiness,

Assess patients fever or pain:type of pain, location, intensity,duration,temperature

TRADE NAME: Napran

hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilation -Relieves pain by inhibiting prostaglandins synthesis at the CNS but does not have antiinflammatory action because of its minimal effect on the peripheral prostaglandin synthesis

-Temporary reduction of fever

dizziness,depression, tremor,headache, seizures Dermatologic: pruritus, urticaria, rash GI: Anorexia, nausea, vomiting, constipation, hepatic insufficiency GU: Hematuria, glycosuria, urinary frequency, renal colic, crystaluria

-Assess allergic reactions: rash, urticaria; if theseoccur, drug mayhave to be discontinued

-Assesss :rapid, weak pulse dyspnea:cold, clammy extremities report immediately to prescriber.

GENERIC NAME AND TRADE NAME

CLASSIFICATIO N

MECHANISM OF ACTION

INDICATIO N

DOSAGE/RO UTE/ FREQUENCY

ADVERSE EFFECT

NURSING RESPONSIBILITIES

GENERIC NAME: FUROSEMIDE 64 | P a g e

Loop Diuretic

Inhibits the reabsorption of sodium and chloride

For hypertension

10mg IVTT with BP

CNS: dizziness, paresthesias,

vertigo, -Administer with food or milk to weakness, prevent GI irritation.

TRADE NAME: Frusema

from the ascending limb of the loop of Henle, leading to sodium rich dieresis.

precaution

headache. CV: Orthostatic thrombophlebitis. hypotension,

-Reduce dosage if given with antihypertensive drugs. -Avoid IV used if oral use is possible.

Dermatologic: photosensitivity, rash, pruritus, urticaria. -Weigh the client in regular basis, at the same time and I the GI: Nausea, vomiting, oral and same clothing and record the gastric irritation, constipation. weight. GU: Polyuria, nocturia, urinary -Blood glucose levels may bladder spasm. become temporarily elevated in Hematologic: leucopenia, patients with DM after starting this drug. anemia, thrombocytopenia.

GENERIC NAME AND TRADE NAME

CLASSIFICATION

MECHANISM OF ACTION

INDICATIO N

DOSAGE/ROU TE/ FREQUENCY

ADVERSE EFFECT

NURSING RESPONSIBILITIE S

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GENERIC NAME: DOPAMINE

Catecholamine ,adrenergic

TRADE NAME: Intropin

Inotropic, vasopressor

Causes norepinephrine release (mainly on dopaminergic receptors), leading to vasodilation of renal and mesenteric arteries. Also exerts inotropic effects on heart, which increases the heart rate, blood flow, myocardial contractility, and stroke volume.

Shock, hemodyna mic imbalance, hypotensio n

250ml @ 65cc/hr

CNS: headache CV: palpitations, hypotension, angina, ECG changes, tachycardia, vasoconstriction, arrhythmias EENT: mydriasis GI: nausea and vomiting Metabolic: azotemia, hyperglycemia Respiratory: dyspnea, asthma attacks Skin: piloerection Other: irritation at injection site, gangrene of extremities (with high doses for prolonged periods or in occlusive vascular disease)

Monitor blood pressure, pulse, urinary output and pulmonary artery wedge pressure during infusion. Inspect I.V.site regularly for irritation. Avoid extravasatio n Monitor color& temp. of extremities. Never stop infusion abruptly, because this may cause severe hypotension. Instead, taper gradually.

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X.

PROGNOSIS

With early and aggressive care, most patients recover from dengue hemorrhagic fever. However, half of untreated patients who go into shock do not survive.

Our patient shows good prognosis.

XI.BIBLIOGRAPHY

BOOKS:

Medical- Surgical Nursing by Ignatavicius and Workman, 5th edition vol.2 Pathophysiology by Porth, 11th edition Medical- Surgical Nursing by Smeltzer and Bare, 11th edition vol.2, Introductory Medical Surgical Nursing by Timby and Smith, 9th edition Medical- Surgical Nursing by Black and Hawks, 6th edition vol.1 Medical- Surgical Nursing: Concepts and Clinical Applications by Udan, 2nd edition Mosbys Pocket Dictionary of Medicine, Nursing, and Allied Health, 4th edition Diagnostic Tests Nurses Quick Check by Williams and Wilkins Nursing spectrum drug handbook 2008 by Patricia Dwyer Schull Nursing care plan by Doenges, Moorhouse and Murr, 7th edition Physical Examination and Health Assessment by Jarvis, 4thed Human anatomy and physiology by Marieb,7th edition, pp.

SUPPLEMENTARY SOURCES:
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http//emedicine.medscape.com/article/238798-overview http//www.merck.com/mmpe/sec17/ch233c.html www.google.com www.askjeeves.com www.dictionrary.com www.about.com http://nursinglectures.blogspot.com/2009/01/post-operative-nursing.html www.medindia.com

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