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I. INTRODUCTION Our client Mr.

JM 8 years old, living in Norzagaray, Bulacan, was d iagnosed with DHF II (Dengue Hemorrhagic Fever stage 2). His primary complaints are abdominal pain, headache and fever. He is a grade three student and studying at FVR elementary school. His parents are Mrs. A 33 years old and Mr. M 42 year s old. Our patient was born in Korean because his parents are working on that co untry. Dengue Fever is caused by one of the four closely related, but antigenica lly distinct, virus serotypes Dengue type 1, Dengue type 2, Dengue type 3, and D engue type 4 of the genus Flavivirus and Chikungunya virus. Infection with one o f this serotype provides immunity to only that serotype of life, to a person liv ing in a Dengue-endemic area can have more than one Dengue infection during thei r lifetime. Dengue fever through the four different Dengue serotypes are maintai ned in the cycle which involves humans and Aedes aegypti or Aedes albopictus mos quito through the transmission of the viruses to humans by the bite of an infect ed mosquito. The mosquito becomes infected with the Dengue virus when it bites a person who has Dengue and after a week it 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 specie which is a domestic, day-b iting mosquito that prefers to feed on humans. .The biggest increase of Dengue c ases in the country was seen in Metro Manila, where there was an almost 200 perc ent increase. According to government figures 15,061 cases of the disease in the Philippines were reported in the first six months of the year. The increase in the number of dengue cases may be attributed to the constantly changing climate brought by global warming as well as congestion in urban areas. Deaths due to de ngue rose to 172 compared with 115 for the first half of 2007. Metro Manila had the highest number of cases, an increase of 191 percent over the same period in 2007.World Health Organization officials earlier this year warned climate change was increasing the incidence of dengue fever and other infectious diseases in t he country. There is no known cure or vaccine for dengue fever, which is transmi tted by the white-spotted mosquito. The Philippines Department of Health (DOH) t oday reported that a total of 2,332 dengue cases has been admitted to sentinel h ospitals nationwide from January 1 to May 15 this year. There were sixteen death s recorded. Partial reports from the DOH National Epidemiology Center (NEC) indi cate a 58% decrease in the number of cases this year compared with the same peri od last year. The NEC report also revealed that the regions with the highest num ber of cases were the National Capital region 1

(732 cases), Region 3 (307), Region 5 (268), and Region 7 (231). The ages of cas es ranged from 1 month to 75 years old, with forty-six percent (535) of the case s belonging to the 1-9 years age group. OBJECTIVES: Knowledge Objectives: To acquire knowledge about DHF. To know the ef fects of DHF to our patient and the right intervention specified for him. To kno w the essentiality of the case that would assist us student-nurses to build a ho listic knowledge, skills and attitude approach to learning . Skill Objective: 1. Identify the risk factors that occur in the disease and make a pathophysiology about the disease. 2. Formulate significant diagnosis that is related to Nursing Care Plan and make a nursing care plan. 3. Identify the medi cations administered to the client and the drugs indication, contraindication, s ide effects, and nurse's responsibility. Attitude Objective: 1. 2. 3. To build trust and rapport to the patient. To gain cooperation and trust from the patient. To gain trust and cooperation from the r elatives of the patient. 2

II. NURSING ASSESSMENT A. PERSONAL DATA NAME: Mr. JM AGE: 8 years old SEX: Male ADDRESS: Friendship Vil lage Resour, Norzagaray Bulacan MARITAL STATUS: Single BIRTHDATE: February 16, 2 002 NATIONALITY: Filipino BIRTHPLACE: Korea EDUCATIONAL ATTAINMENT: Grade 3 stud ent POSITION IN THE FAMILY: Son RELIGION: Roman Catholic HEALTH CARE FINANACING AND USUAL SOURCES OF MEDICAL CARE: Mother DATE ADMISSION: September 6, 2010 TIME : 1:20 pm B. CHIEF COMPLAINT Mr. JM was admitted to Bulacan Medical Center with a chief complaint of abdominal pain and headache. C. HISTORY OF THE PRESENT ILLN ESS The client experienced having abdominal pain every time his stomach is full. He was just lying on bed when the abdominal pain started. He was brought by his mother to Roquero hospital because of having fever, abdominal pain and headache and after 2 days he was transferred to BMC because his family observes having n o improvement on their son's situation. He was given Ampicillin and Augmentin at t he Roquero hospital. He was given Ranitidine at the BMC hospital for treatment o f the abdominal pain. D. HISTORY OF THE PAST ILLNESS The client doesn't have any a llergies and haven't encountered any accident or injuries. He has completed his im munization according to his aunt. It was his second hospitalization because he w as just transferred to BMC. He just had taken Paracetamol every time he experien ce having fever and headache. 3

E. FAMILY HEALTH ILLNESS HISTORY GENOGRAM HM 84 Y/O HPN EM 73 Y/O YC 89 Y/O KC 7 6 Y/O OM 47 Y/O KM 44 Y/O MM 42 Y/O AM 33 Y/O AC 30 Y/O MALE FEMALE PATIENT DECEASED ASTHMA Arthritis HPN Hypertension JM 8 Y/O The client is the only child of Mr. M.M and Mrs. A.M. He was born in Korea where his parents are working; when he was around 26 days old that's the time he was br ought here in the Philippines. It was the first incidence of having Dengue in th eir family. His grandfather has arthritis and hypertension while his grandmother has asthma and the rest of the families are healthy. 4

F. FUNCTIONAL HEALTH PATTERN A. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN The client's health has been better. Prior to hospitalization he has no colds but if it happens their first aid is to drink herbal medicines and if it doesn't work they will seek for a doctor's consultation. They think that the illness is caused by the poor sanitation of the place where they stayed at Tondo, Manila and when they went to Norzagaray, Bulacan that's when the symptoms started. He was rushed t o the hospital after experiencing abdominal pain, headache and high fever. B. NU TRITIONAL AND METABOLIC PATTERN The client loves to eat fried chicken and he alw ays eats fruits every breakfast and drinks milk twice a day. He also has a good appetite prior to hospitalization, while during hospitalization he has poor appe tite because of the feeling of weakness and he doesn't like the food. During his h ospitalization, he is restricted by his doctor to eat dark colored foods. He doe sn't have any skin problems or any dental problems. C. ELIMINATION PATTERN The cli ent urinates 4x a day during his hospitalization with a yellowish color about 10 0 ml per voiding. He defecate once a day everyday with a formed color brown stoo l. URINE STOOL AMOUNT 100 ml FREQUENCY 4 times a day Once a day COLOR Yellow Bro wn ODOR Pungent Foul D. ACTIVITY-EXERCISE PATTERN Mr. JM has sufficient energy for completing his des ired activities, like during playing and doing activities at school. During his spare time he would play outdoor activities with his neighbors. 0-Feeding 0-Dres sing IV- Home maintenance 0-Bathing 0-Grooming II-Shopping 0-Toileting 0-General Mobility 0-Bed Mobility IV-Cooking 5

Level 0- full self care Level I- requires use of equipment or device Level II- r equires assistance or supervision from another person Level III- requires assist ance or supervision from another person or device Level IV- is dependent and doe s not participate E. SLEEP-REST PATTERN The client has a regular sleeping patter n because of having 10 hrs. of sleep starting from 8pm-5am. He has a continuous sleep and often takes nap in the afternoon after school. He doesn't have any probl em falling asleep. F. COGNITIVE PERCEPTUAL PATTERN The client has no difficulty in hearing and on vision. He learned through school and family. Prior to hospita lization, he experienced abdominal pain and headache and he took Paracetamol to lessen the pain that he is experiencing, G. SELF-PERCEPTION AND SELF-CONCEPT PAT TERN He felt good about himself. Since the illness started he missed some of his classes in school. He felt angry every time he wouldn't get what he wanted and be ing tearful every time he was forced to do something he wouldn't like to do. H. RO LE-RELATIONSHIP PATTERN He belongs to an extended family. Every time they have a problem they will just communicate with each other to solve the issue. His pare nts are really affected with his hospitalization because they are not here to ta ke care of him. His relatives were the one taking good care of him while he in t he hospital. I. SEXUALITY-REPRODUCTIVE PATTERN Not applicable J. COPING STRESS T OLERANCE PATTERN He had no big problem in his life, sometimes he experience havi ng fight with his playmates but still they where able to solve it by themselves. 6

K. VALUE-BELIEF PATTERN The client is a catholic and they believe in God. For th eir family it is really important to have a connection to God. It really helps e very time they are facing a problem and during his stay in the hospital his fami ly is praying for his wellness. G. GROWTH AND DEVELOPMENT PSYCHOSOCIAL STAGE Sch ool Age Industry vs. Inferiority Latency (Genital Stage) Concrete Operations Pha se Conventional (Interpersonal Concordance Orientation Stage) At Conventional le vel, person is concerned with maintaining expectations and rules of the family, group, nation, or society. A sense of guilt has developed and affects behavior. The person values conformity, loyalty, and active maintenance of social order an d control. Conformity means good behavior or what pleases or helps another and i s approved Societal focus. In interpersonal concordance orientation he decisions and behavior are based on concerns about other's reaction; the person wants other s approval or a reward. PSYCHOSEXUAL COGNITIVE MORAL DEFINITION At this stage, the children begin to create and develop a sense of competence an d perseverance. They are motivated by activities that provide a sense of worth. They concentrate on mastering skills that will help the, function in the adult w orld. Although children of this age work hard to succeed, they are always faced with the possibility of failure, which can lead to a sense of inferiority. If ch ildren have been successful in previous stages, they are motivated to be industr ious and to cooperate with others toward a common goal The stage begins around the time that children enter into school and become more concerned with peer relationships, hobbies, and other interests. The latent per iod is a time of exploration in which the sexual energy is still present, but it is directed into other areas such as intellectual pursuits and social interacti ons. This stage is important in the development of social and communication skil ls and self-confidence. Cognitive development refers to the manner in which people learn to think, reaso n, and use language. It involves a person's intelligence, perceptual ability, and ability to process information. At concrete operations phase it solves concrete problems. The child begins to understand relationships such as size. They unders tand right and left. The child has cognizant of viewpoints. In this stage (chara cterized by 7 types of conservation: number, length, liquid, mass, weight, area, volume), intelligence is demonstrated through logical and systematic manipulati on of 7

symbols related to concrete objects. Operational thinking develops (mental actio ns that are reversible). Egocentric thought diminishes. ANALYSIS Our client has reached this stage. He is a grade 3 student; through social interactions to his classmates and friends he developed a sense of pride in his accomplishments and abilities. According to our patient, he is always encouraged and commended by hi s parents and teachers when he did something good. By encouraging and commending a child, our client developed a feeling of competence and belief in his skills. He also stated, that his parents always letting him to do what he wants to do b ut within the scope of his age. Mr. JM developed a strong sexual interest in his opposite sex like his friends. According to him, during his earlier age (around 5 to 7 years old) he was solely focus on his individual needs and interests in the welfare of others. He also stated that he is always socialized to his friend s and classmates during their spare time in school. Our client thinks logically about concrete events, but has difficulty understanding abstracts or hypothetica l concepts. He also understands the awareness that actions can be reversed becau se he is able to reverse the order of relationships between categories. Our clie nt stated that his parents always calling him as a good-boy because according to h im he is always following the saying and rules of his parents. 8


THE SYSTEMIC CIRCULATION Major arteries (in bright red) and veins (dark red) of the system Blood from the aorta passes into a branching system of arteries that lead to all parts of the body. It then flows into a system of capillaries where its exchange functions take place. Function only: to supply materials to and rem ove materials from the capillaries. Blood from the capillaries flows into venule s which are drained by veins. BLOOD Blood is a liquid tissue. Suspended in the w atery plasma are seven types of cells and cell fragments. red blood cells (RBCs) or erythrocytes platelets or thrombocytes kinds of white blood cells (WBCs) or leukocytes Three kinds of granulocytes neutrophils 10 Veins draining the upper p ortion of the body lead to the superior vena cava. Veins draining the lower part of the body lead to the inferior vena cava. Both empty into the right atrium.

eosinophils basophils Two kinds of leukocytes without granules in their cytoplasm lymphocytes monocyte s

FUNCTIONS OF THE BLOOD Blood performs two major functions: transport throug body of oxygen and carbon dioxide food molecules (glucose, lipids, amino acids) ions (e.g., Na+, Ca2+, HCO3-) wastes (e.g., urea) hormones heat Defense of the bo dy against infections and other foreign materials. All the WBCs participate in t hese defenses 11

All the various types of blood cells Are produced in the bone marrow (some 1011 of them each day in an adult human!). Arise from a single type of cell called a multipotent stem cell. These stem cells are very rare (only about one in 10,000 bone marrow cells); are attached (probably by adherens junctions) to osteoblasts lining the inner surfa ce of bone cavities; produce, by mitosis, two kinds of progeny: More stem cells (A mouse that has had all its blood stem cells killed by a lethal dose of radiat ion can be saved by the injection of a single living stem cell!). Cells that begin to differentiate along the paths leading to the various kinds of blood cells. 12

IV. THE PATIENT AND HIS ILLNESS A. PATHOPHYSIOLOGY (Schematic Diagram) Non Modifiable Factors; -age Modifiable Factors; -environment (sanitation) Bite of aedes mosquito Dengue flavi virus mix in the blood circulation Immune sy stem recognizes the viral invasion; triggers immune response - WBC 13

Macrophages will release pyrogens that would stimulate the thalamus to - body temp . Megakaryocytes desentigrate as core body temp. continue to rise which would resu lt to platelet count. Platelet count would now decrease the clothing capability - hemorrhage Hemorrhage in the micro circulation of the gums (that could cause bleeding gums) 14

PHYSICAL ASSESSMENT Name: Mr. JM Birthday: February 16, 2002 Age: 8 y/o Date of Assessment: Sept. 08, 2010 Weight: 27 kg. Height: 4'11 Parts to be Examined 1. GEN ERAL SURVEY Body built, height & weight in relation to client's age, lifestyle and health Client's posture and gait, standing, sitting and walking Client's overall hy giene and grooming Body and breath odor Technique Inspection Vital signs: Temper ature: 38.4C Pulse rate: 90 bpm Respiratory rate: 35 cpm Blood pressure: 100/70mm Hg BMI: 12.0 Normal Findings Proportionate, varies with lifestyle Relaxed, erect posture; coordinated movement Clean, neat No body odor or minor body odor relat ive to work or exercise; no breath odor Actual Findings He has a proportionate b ody built which is appropriate with his lifestyle He is slightly unrelaxed and h as minimal movements He dresses cleanly, neatly and appropriately. He has no bod y & breath odor. Interpretation Normal Deviation from Normal due to discomfort a nd illness. Normal Normal Inspection Inspection Inspection 15

Clinical Measurements Height Weight Underweight = <18.5 Inspection Normal weight = 18.524.9 Overweight = 25-29.9 Obe sity = BMI of 30 or greater Inches 4'11 27 kg. BMI =12.0 The client is underweight based on the result of BMI. Vital Signs Temperature Pulse rate Respiratory Rate Blood Pressure BEHAVIOR Sign s of distress, in posture or facial expression Signs of health or illness Client's attitude Client's affect/mood; appropriateness of client's response Quantity of spe ech, quality Inspection Palpation Inspection Auscultation and Palpation Inspection Inspection Inspection Inspection Inspection 36.5-37.5 C 60-100bpm 12-21cpm 120/80mmhg 38.4 C 90bpm 35cpm 100/70mmhg Temperature are elevated due to increased WBC No distress noted Healthy appearance Cooperative, able to follow instructions Ap propriate to situation Understandable, moderate pace; clear tone and inflection; On stress He has an unhealthy appearance He is very cooperative and able to foll ow my instructions He responds appropriately He speech is slightly understandabl e,clear and has association of Deviation from Normal due to hospitalization. Deviation from Normal due to illne ss. Normal Normal Normal 16

Relevance and organization of thoughts 2. INTEGUMENTARY A. SKIN Color and unifor mity of color Inspection exhibit thought association Logical sequence; makes sense; has sense of reality thoughts He has relevance of thoughts that makes sense and has a sense of realit y Normal Inspection Presence of edema Presence of lesion according to location, distribution, color, configuration, size, shape, type or structure Skin moisture Inspection Inspection Varies from light to deep brown; ruddy pink to light pink; from yellow overtones to olive Generally uniform except in areas exposed to the sun; areas of lighter pigmentation in darkskinned people No edema Freckles, some birthmarks, some fla t and raised nevi; no abrasions or other lesions Moisture in skin folds and axil lae (varies with environmental temperature and humidity and activity) Uniform; w ithin Pale in color, Herman signs are present Deviation from Normal d/t decreased tissue perfusion & peripheral vasoconstricti on. He has edema on the IV site He has no lesion; no abrasions or other lesions Deviation from normal d/t IV infusion Normal Deviation from Normal d/t uncomfort able environment. Deviation from Inspection He has warm and silky skin moisture. His skin temperature Skin temperature Palpation 17

normal range Skin turgor B. NAILS Fingernail's shape, curvature and angle Fingerna il and toenail texture Fingernail and toenail bed color Palpation Skin springs b ack to previous state; has a good skin turgor Convex curvature; angle of nail pl ate about 160 No visible lines and cracks Smooth texture Highly vascular and pin k in light-skinned people; dark-skinned may have brown or black pigmentation in longitudinal streaks Intact epidermis Blanch test of capillary refill Palpation Prompt return of pink or usual color; Delayed 1-2 sec is warm With redness when pinched His nail has a convex curvature approximately 160 He has a smooth nails without any damages Pallor normal due to increase body temperature Deviation from Normal d/t blood circulat ion Normal Normal Deviation from Normal d/t poor arterial circulation. Inspection Palpation Inspection Tissues surrounding nails Inspection He has an intact epidermis with no hangnails There is a prompt return of blood r esulting to the usual color, delayed for 4 sec. His skull is rounded and has a s mooth skull contour He has no nodules and masses Normal Deviation from Normal d/t poor arterial circulation. 3. HEAD A. SKULL Size, shape and symmetry Presence of nodules, masses and depres sions Inspection Palpation Rounded (normocephalic); smooth skull contour Smooth, uniform consistency; absen ce Normal Normal 18

of nodules and masses B. SCALP Color and appearance Areas of tenderness C. HAIR Evenness of growth, thickness and thinness Texture, oiliness over the scalp Colo r D. FACE Facial features, symmetry of facial movements 4. EYES Inspect the eyes for edemas and hallowness A. EYEBROWS Evenness of distribution and direction of curl Inspection Palpation Inspection Palpation Inspection Inspection Usually wh ite but it also depends on darkskinned people No tenderness Evenly distributed t hick hair Smooth texture; no oiliness Black Symmetrical facial features and move ments No edema No edema Normal His scalp is white and has a smooth surface There are no areas of tenderness He has a thick hair and it is evenly distributed He has a smooth scalp and oily and brittle hair. Black with short hair. He has asym metrical facial features which has asymmetrical movements Normal Normal Normal D eviation from normal due to hospitalization. Normal Deviation from Normal d/t il lness and hospitalization. Inspection Inspection Hair evenly distributed and the curl is outward He has an evenly distributed hair in her eyebrow and they are aligned with equal movement His eyelashes are equally distributed and curled outward Normal B. EYELASHES Evenness of distribution and direction of curl Inspection Equally distributed; curls slightly outward Normal 19

C. EYELIDS Surface characteristics, position in relation to the cornea, ability to blink and frequency of blinking Inspection Skin intact; no discharge or discoloration; Lids closed symmetrically approximat ely 15-20 involuntary blinks per minute Transparent capillaries sometimes eviden t Shiny, smooth and pink or red Sclera appears white Transparent, shiny and smoo th; the details of iris are visible Rounded shape which are the same in each eye ; color varies depending on the race and the color is evenly distributed Black i n color, equal He has a smooth eyelids with no discharge; lids closed symmetrically and has 1520 blinks per minute His Bulbar Conjunctiva is transparent and has some visible small capillaries He has shiny, smooth and reddish palpebral conjunctiva He has white sclera He has a transparent, shiny and smooth cornea He has a dark brown i ris which is uniform and they are both rounded Normal D. CONJUNCTIVA Bulbar Conjunctiva for color, texture and presence of lesions Inspection Normal Palpebral Conjunctiva for color, texture and presence of lesions E. SCLERA Color and clarity F. CORNEA Clarity and texture Inspection Deviation from Normal d/t blood circulation. Normal Normal Inspection Inspection G. IRIS Shape and color Inspection Normal H. PUPILS Color, shape and symmetry of size Inspection His pupils are black, Normal 20

in size and smooth border I. VISUAL ACUITY Near Vision Distant Vision Inspection Inspection Able to read newsprints When looking straight ahead, client can see objects in the periphery Illuminated pupils constricts Pupils also constricts wh en looking at near objects, dilate when looking at far objects and converge when near object is moved toward the nose No edema, tenderness or tearing Both eyes coordinated, move in unison, with parallel alignment When looking straight ahead , client can see equal in size and has smooth borders He has been able to read newsprints with th e use of eye glasses N/A (no equipment) Normal N/A J. PUPILS Inspection Light reaction and accommodation His pupils constrict when light passes and it also converge when near object is moved toward his nose Normal 5. LACRIMAL GLAND / SAC & NASOLACRIMAL DUCT Lacrimal Gland A. EXTRAOCULAR MUSCLE S Alignment and coordination Inspection and palpation Inspection There are no edema, tenderness and tearing noted from the client His both eyes a re coordinated, move in unison with parallel alignment He can see objects in the periphery Normal Normal B. VISUAL FIELD Peripheral visual fields Inspection Normal 21

objects in the periphery 6. EARS A. AURICLES Color, symmetry of size and positio n Inspection Color same as facial skin; symmetrical; auricle aligned with outer canthus of eye about 10 vertical Mobile, firm and not tender; pinna recoils afte r being folded Dry cerumen, grayish-tan color, sticky or wet cerumen in various shades of brown Normal voice tones audible Able to hear ticking sound in both ea rs Sound is heard at both ears or at the center (Weber's negative) Air conduction is greater than the bone conduction (Rinne Positive) His ears' skin color is same as the surrounding skin and both are symmetrical; the auricles are aligned in th e outer canthus of each eye His auricles are mobile, firm and not tender; his pi nna recoils when folded He had no visible cerumen, has a grayish color Normal Texture, elasticity and areas of tenderness B. EXTERNAL EAR CANAL Cerumen, skin lesions, pus and blood Palpation Normal Inspection Normal C. HEARING ACUITY TESTS Client's response to normal voice tone Watch tick test Web er's test Rinne test Inspection Inspection Inspection Inspection His voice tones is audible He can hear ticking sound in both ears He heard at bo th ears or at the center (Weber's negative) Air conduction is greater than the bon e conduction (Rinne Positive) Normal Normal Normal Normal 22

7. NOSE Deviations in shape, size or color and flaring or discharge Nasal caviti es for presence of redness, swelling, growths and discharge Nasal septum between the nasal chambers Patency of both nasal cavities Tenderness, masses and displa cement of bones and cartilage SINUSES Tenderness 8. MOUTH A. LIPS Symmetry of co ntour, color and texture Inspection Inspection Inspection Inspection Palpation Symmetric and straight; no discharge or flaring; uniform color Mucosa pink; clea r watery discharge; no lesions Nasal septum intact and in midline Air moves free ly as the client breathes through the nares Not tender His nose are uniform in color same as with the surrounding skin; there are no di scharge and flaring He has a clear watery discharge and has no apparent lesions His nasal septum is in the middle He usually breathes freely through his nares T here are no tenderness, masses or displacement of bones and cartilage His sinuse s are not tender He has a pale in color lips, slightly dry and smooth; it has sy mmetry of contour and has the ability to purse his lips He has a moist, soft, gl istening and elastic texture of his buccal mucosa Normal Normal Normal Normal Normal Palpation Not tender Normal Inspection Uniform pink color, soft, moist, smooth texture, symmetry of contour, ability to purse lips Moist, smooth, soft, glistening and elastic texture Deviation from Normal d/t illness. B. BUCCAL MUCOSA Color, moisture, texture and presence of lesions Inspection Normal 23

C. TEETH Color, number, condition and presence of dentures D. GUMS Color and con dition E. TONGUE/ FLOOR OF MOUTH Color and texture of the mouth and frenulum Inspection Pre-schooler teeth; smooth, white and shiny tooth enamel Pink gums; moist and fi rm texture to gums; no retractions Central position; Pink color, moist, slightly rough; thin whitish coating, lateral margins; no lesions; raised papillae Moves freely; no tenderness; smooth tongue base with prominent veins Smooth with no p alpable nodules Light pink, smooth, soft palate Lighter pink hard palate, more i rregular Positioned in midline of soft palate Pink and smooth posterior walls Pi nk and smooth; no discharge; of normal He has a shiny tooth enamel without any dental problems His gums are pinkish to reddish in color His tongue is in the center, pink in color, it is moist, slight ly rough without lesions; it has a thin whitish coating and lateral margins His tongue moves freely with weak tenderness It has no nodules He has pale in color and smooth soft palate while pale and irregular hard palate The uvula is in the middle He has a smooth and pinker posterior walls His tonsils are pink and smoot h without Normal Deviation from normal due to bleeding Inspection Inspection Normal Position, color and texture, movement and base of tongue Presence of nodules, lu mps or excoriated areas F. PALATES AND UVULA Color, shape, texture, and presence of bony preminences Position of uvula and mobility while examining the palates. G. OROPHARYNX AND TONSILS Color and texture Size of tonsils, color and discharg e Inspection and palpation Palpation Inspection Normal Normal Deviation from Normal d/t decrease blood circulation Normal Normal Normal Inspection Inspection Inspection 24

size Presence of Gag reflex 9. NECK A. LYMPH NODES Lymph Nodes and tenderness B. TRACHEA Placement Inspection Gag reflex is present discharge and of normal size He has a positive gag/cough reflex His nodes are no t palpable His trachea is in the middle with equal spaces on both sides It is no t visible His thyroid glands rise when swallowing; it is smooth and painless Normal Inspection and palpation Inspection and palpation Not palpable Central placement in midline of neck; spaces are equal in both side s Not visible on inspection Glands ascends during swallowing; painless, centrall y located and smooth Chest symmetric; anteroposterior to transverse diameter in ratio of 1:2 Spine vertically aligned Skin intact; uniform temperature Full and symmetric Normal Normal C. THYROID GLAND Symmetry and visible masses Smoothness, enlargement and nodules 10. THORAX A. POSTERIOR Shape, symmetry, compare the diameter of anteroposterio r to transverse diameter Spinal alignment Temperature, tenderness and masses Res piratory excursion Inspection Palpation Normal Normal Inspection Inspection Palpation Inspection and His chest are symmetric; anteroposterior to transverse has a diameter ratio of 1 :2 His spine is vertically aligned His skin is intact and has uniform warm tempe rature He has a full and Normal Normal Normal Normal 25

palpation Vocal fremitus Palpation Percuss the thorax Percussion Auscultate the thorax B. ANTERIOR Breathing patterns Temperature, tenderness and masses Respiratory excursion Auscultation expansion; as the client breathes, thumbs usually separates 3-5cm Bilateral symm etry of vocal fremitus; it is heard mostly at the apex of lungs Percussion notes resonance except over scapula Lowest point of resonance is at the diaphragm Ves icular and bronchovesicular sounds Quiet, rhythmic and effortless respiration Sk in intact; uniform temperature Full and symmetric expansion; as the client breat hes, thumbs usually separates 3-5cm Bilateral symmetry of vocal fremitus; it is heard mostly at the apex of lungs symmetric expansion and as she breathes, thumbs usually separate for 3-5 cm. He has a bilateral symmetry of vocal fremitus; it is heard clearly at the apex His percussion notes resonance sound except over the scapula and the lowest resonanc e heard is at the diaphragm There are vesicular and bronchovesicular sounds hear d He has a quiet, rhythmic and effortless respiration His skin is intact and has uniform warm temperature He has a full and symmetric expansion and as he breath es, thumbs usually separate for 3-5 cm. He has a bilateral symmetry of vocal fre mitus; it is heard clearly at the apex Normal Normal Normal Inspection Palpation Inspection and palpation Normal Normal Normal Vocal fremitus Palpation Normal 26

Percuss the anterios thorax Percussion Auscultate the trachea Auscultate the thorax 11. CARDIOVASCULAR Aortic and pulmo nic areas Tricuspid area Apical area Auscultation Auscultation Percussion notes resonance except over ribs Lowest point of resonance is at the diaphragm Bronchial or tubular breath sounds Vesicular and bronchovesicular soun ds No pulsation No pulsation; no lift or heave Some pulsations visible; no lift or heave Aortic pulsations S1-usually heard at all sites but louder at the apica l area S2-usually heard at all sites but louder at the base of heart Symmetric p ulse volumes; full pulsations His percussion notes resonance sound except over the ribs and the lowest resonan ce heard is at the diaphragm There are bronchial or tubular sounds heard There a re vesicular and bronchovesicular sounds heard No pulsations felt No pulsations or lift and heave There are some pulsations felt but there are no lift or heave There are aortic pulsations There are heart sounds heard in all sites Normal Normal Normal Inspection and palpation Inspection and palpation Inspection and palpation Inspe ction and palpation Auscultation Normal Normal Normal Epigastric area Auscultate aortic, pulmonic, apical, tricuspid and epigastric ar ea Normal Normal 12. CAROTID ARTERIES Palpate with extreme caution Palpation His carotid artery has a full symmetric pulse volumes and pulsations Normal 27

Auscultate the carotid arteries 13. JUGULAR VEINS Presence of veins 14. ABDOMEN Skin integrity Abdominal contour Enlarged liver or spleen Symmetry of contour Ab dominal movements Vascular patterns Bowel sounds, vascular sounds and peritoneal friction rubs Auscultation Inspection Inspection Inspection Inspection Inspection Inspection I nspection Auscultation No sounds heard Veins not visible Unblemished skin, uniform color Flat, rounded or scaphoid No evidence of enlarged liver and spleen Symmetric contour Symmetric movements caused by respiration No visible vascular patterns Audible bowel soun ds usually occur every 520seconds; absence of arterial bruits and friction rub T ympany over stomach and gasfilled bowels; dullness over the liver and spleen or full bladder No tenderness, relaxed abdomen with smooth, consistent There are no sounds heard There are no visible veins He has unblemished skin, un iform color He has symmetric contour There are no evidence of enlarged liver and spleen He has a symmetric contour He has symmetric movements because of respira tion There are no vascular patterns seen There are audible bowel sounds heard ev ery 30 seconds but no arterial bruits and friction rub There is tymphany over st omach and gas filled bowels There is no tenderness, his abdomen is relaxed with smooth consistent Normal Normal Normal Normal Normal Normal Normal Normal Normal Percuss in each quadrants Percussion Normal Light palpation of quadrants Palpation Normal 28

tension 15. MUSCULOSKELETAL A. MUSCLES Size, comparison on one side to other sid e Contractures Fasciculation and tremors Muscle tonicity Muscle strength B. BONE S Normal structure and deformities Edema and tenderness C. JOINTS Swelling Inspe ction Inspection Inspection Palpation Inspection and Palpation Inspection Palpat ion Equal size on both sides of the body No contractures No tremors Normally fir m Smooth coordinated movements No deformities No tenderness or swelling No swell ing tension He has equal muscle size on both sides of the body He has no contracture s He has no tremors He has firm muscles He has a weak and slight un-coordinated movements He has no deformities He has no edema, tenderness and swelling Positiv e swelling Normal Normal Normal Normal Deviation from Normal d/t illness. Normal Normal Inspection Deviation from Normal d/t uncomfortable environment. Normal Tenderness, smoothness of movements, crepitation and nodules Palpation No swelling, tenderness, crepitation or nodules There are no tenderness, swelling, crepitation or nodules; 29

Joint range of motion Inspection Varies to some degree in accordinance with person's genetic makeup and degree of p hysical ability. He has a good joint ROM. Normal 30


Diagnostic Laboratory Procedure Complete Blood Count Date Ordered Sept. 07, 2010 `Indication or Purpose The CBC provides valuable information about the blood and to some extent the bone marrow, which is the blood-forming tissue. The CBC is u sed for the following purposes: as a preoperative test to ensure both adequate o xygen carrying capacity and hemostasis to identify persons who may have an infec tion to diagnose anemia to identify acute and chronic illness, bleeding tendenci es, and white blood cell disorders such as leukemia to monitor treatment for ane mia and other blood diseases To determine the effects of chemotherapy and radiat ion therapy on blood cell production. Result Normal Values Analysis and Interpretation of Result Analysis/Interpretation Abnormal/Decreased Abnormal/Elevated Normal Normal Abnormal/Decreased Abnormal/Decreased Abnormal/ Decreased Normal Abnormal/Elevated Abnormal/Elevated Normal Normal Normal Abnorm al/Decreased Abnormal/Elevated Abnormal/Decreased Normal Normal Nursing Responsibilities Before: -Identify the patient -explain the procedure to the patient -Inform the patient that there are no foods, fluids, or medications restrictions, unless by medical directions. During: -Instruct the patient to co operate fully and to follow directions during the laboratory procedures. After: -Secure the laboratory results of the patient. Components WBC RBC HGB HCT PLT PCT MCV MCH MCHC RDW MPJ PDW %Lymphocytes #Lympho cytes %Monocytes #Monocytes %Granulocytes #Granulocytes Actual Findings 2.2 L 109/L 6.20 H 1012/L 100 g/L 0.330 69 L 109/L 0.046 L 10-2/ L 72 L fl 25.5 L pg 356 H g/L 16.7 H% 6.6 fl 10.1 % 39.3 % 0.8 L 109 L 13.3 H% 0 .2 L 109L 47.4 % 1.2 L 109L

Normal Findings 3.5 10.0 3.80 5.80 110 165 0.350 0.500 150 390 0.100 0.500 80 9 26.5 33.5 315 350 10.0 15.0 6.5 11.0 10.0 18.0 17.0-48 1.2-3.2 4.0-10.0 0.3-0.8 43.0-76.0 1.2-6.8 32

V. THE PATIENT AND HIS CARE A. MEDICAL MANAGEMENT a. IVF, BLOOD TRANSFUSION, NEBULI ZATION, TOTAL PARENTERAL NUTRITION, NGT, OXYGEN THERAPY ETC. MEDICAL MANAGEMENT DATE ORDERED, DATE RESULT IN GENERAL DESCRIPTION INDICATION/ PURPOSES CLIENT'S RESPONSE NURSING RESPONSIBILITIES D5 0.3 NaCl 500 cc @ 25 gtts/ min September 6, 2010 Hypertonic Crystalloid Sterile, nonpyrogenic and contain no ba cteriostatic or antimicrobial agents. It contains 77 mEq/L solution and 77 mEq/L chloride. Hypertonic solution draws fluids from the ICF causing cells to shrink and ECF to expand. Given to patients with hyponatremias (Na deficits) with edema. IVF may also come in a form of nutrient solution, electrolyte solution, alkalyzing solut ion & acidifying solution. The patient gets sufficient energy for the body and the brain to function well. -Frequently check the IVF site for infiltration, dislodge and inflammation -Expl ain the purpose of the IVF to the patients' family. 33

Normal Saline Solution 250 cc as fast Drip September 06, 2010 Solution of common salt in distilled water, of a strength of 0.9 per cent. It is called normal saline because the percentage of salt resembles that of the cryst alloids in the blood plasma. Applied to a wound an isotonic causes no increase i n the flow of lymph from the capillary blood vessels. -Can be use to replace fluids in dehydration, go with blood transfusion, hyponat remia, and burn victims. It is isotonic. -to dilute medications and to clean wou nds out and to clean wounds out and other things. -fast drip for low BP in dengu e hemorrhagic fever patient. The patient gets sufficient energy for the body and the brain to function well. -monitor for urine output, which should be 100ml or more every 4hrs. -assess IV site carefully to avoid extravasations and tissue necrosis. -monitor renal funct ion, urinary output, fluid balance and electrolytes level. b. Drugs Generic/ Brand name Ranitidine Hydrochloride (Zantac, Gavilast, Aporani tidine.Ranitil Ulzan) Date ordered, date taken/Given, date changed, date discont inued September 6, 2010 Route of administration, dosage, frequency 250mg TIV q 8 General action, classification, mechanism of action Histamine-receptor antagonis t Anti ulcer drug Reduces gastric secretion and increases gastric Indication/ pu rposes Treatment of active duodenal ulcer; maintenance therapy for duodenal ulce r patient after healing of acute Client's response Nursing responsibilities (Prior , during, after) Assess vital signs. Monitor CBC and liver function tests. Asses s patient for epigastric or abdominal pain and 34 No signs of any adverse reaction.

mucus and bicarbonate production, creating a protective coating in gastric mucos a. ulcer; treatment of gastro esophageal Reflux disease: short-term treatment of ac tive, benign gastric ulcer; treatment of pathologic GI hypersecretory conditions (e.g., Zollinger-Ellison syndrome, systemic mastocytosis, and postoperative hyp ersecretion); heartburn. frank or occult blood in the stool, emesis, or gastric aspirate. Inform patient that it may cause drowsiness or dizziness. Inform patient that increased fluid a nd fiber intake may minimize constipation. Advise patient to report onset of bla ck, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or h allucinations to health care professional promptly. c. Diet Type of diet Date started Date changed/D/C General description Indicatio ns/Purposes Specific Foods taken Client response to the diet DAT except dark colored food September 6, 2010 A human being pattern of res nutritious, Any food except dark colored eating. foods that he desi

All nutritious food except dark colored The patient obeys and maintained the 35

It simply means "eat anything you want except dark colored foods. if this will not lead to any complications and if the client needs further monit oring for lab test foods such as chocolates, dinuguan, squid, etc. instructed diet. d. ACTIVITY/ EXERCISE TYPE OF EXERCISE DATE ORDERED/ DATE STARTED/ DATE DISCONTI NUED GENERAL DESCRIPTION INDICATIONS/ PURPOSES CLIENT'S RESPONSE TO ACTIVITY NURSI NG RESPONSIBILITIES 36

Regular physical activity September 6, 2010 important taining a strength, al risks, for maintaining physical fitness and can contribute positively to main healthy weight, building and maintaining healthy bone density, muscle and joint mobility, promoting physiological wellbeing, reducing surgic and strengthening the immune system.

-improve the range of motion of muscles and joints. - increasing cardiovascular endurance. The patient can regain the strength he has lost in the days of his hospitalizati on -explain to the patient the importance and benefits of having a regular exercise . -encouraged the relative or family to join in the activity. -give some exercis es that the patient can do that can't cause him any stress. NURSING CARE PLAN CUES NURSING DIAGNOSIS SCIENTIFIC KNOWLEDGE GOALS/ OBJECTIVES NURSING RATIONALE EVALUATION/ EXPECTED 37

INTERVENTION Subjective: Nahihilo, nanghihina at sumasakit ang tiyan ko as verbali zed by the patient. Ineffective Tissue Perfusion r/t Decreased hemoglobin concen tration in blood AEB low hemoglobin concentration, pallor and dizziness, and mus cle weakness. Typhoid Ileitis & DHF After 12 hours of 1. nursing intervention, 1 . a.) Encourage 2. the client will be able patient to take to: iron supplements and 1. Demonstrate eat foods rich in different ways to iron. improve blood b.) E levate head of oxygenation and bed to about 10 circulation. degrees. 2. Verbaliz e understanding of condition and importance of treatment regimen. 3. Demonstrate increased tissue perfusion. c.) Discourage strenuous activities. 2. a.) Provide health teaching regarding DHF and Typhoid Ilietis b.) Provide health teaching o n drugs being taken. 3. a.) Monitor vital signs . OUTCOME 1. a.)To help After 32 hours of elevate nursing intervention hemoglobin and the client was: hematocrit levels 1. Demonstrated different ways to b.) To p romote improve blood circulation and oxygenation and venous drainage. circulatio n. c.)To avoid increased oxygen demand. 2. a.) To help client understand his hea lth condition. b.)To maintain compliance to meds. 2. Verbalized understanding of condition and importance of treatment regimen. 3. Demonstrated increased tissue perfusion Viral infection Objective: Pallor Hemoglobin = 100 g/L Hematocrit = 0.330 L/L Decreased CBC & platelet count Definition: Decrease in oxygen resulting in the failure to nourish the tissues a t the capillary level [Tissue perfusion problems can exist without decreased car diac output; however there may be a relationship between cardiac output and tiss ue perfusion.] Decreased level of hemoglobin and hematocrit Decreased blood oxygenation pallor, dizziness, muscle weakness 3. a.)Serve as basis for any alteration in system functions. 38

Ineffective tissue perfusion Source: Nurse's Pocket Guide Ninth Edition b.) Encourage early ambulation when possible. b.) Enhances venous return. Collaborative: Administer medications as ordered Administer and regulate IVF as ordered Administer packed RBC's Monitor lab studies ( Hb,Hct, RBC count) Help control/alleviate symptoms Maintain hydration and help wash away toxins Pac ked RBC's are adequate for stable patients with subacute/chronic bleeding to incre ase oxygen carrying capability. Aids in establishing blood replacement needs & m onitoring effectiveness of 39

Source: Nurse's Pocket Guide Ninth Edition therapy. Source: Nurse's Pocket Guide Ninth Edition CUES NURSING DIAGNOSIS SCIENTIFIC KNOWLEDGE GOALS/ OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION/ EXPECTED OUTCOME Infectious agents (pyrogens) Subjective: Mainit ang pakiramdam ko as verbalized b y the patient. Objective: Flushed skin, warm to touch. Hyperthermia related to i nflammatory response as manifested by body temperature of 38.6 degree Celsius, f lushed and warm to touch skin. After 4 hrs. Of nursing interventions, the patien t will maintain core temperature within normal range. Independent: Rendered tepi d sponge bath Encouraged to increase fluid intake Promoted surface cooling, loos en clothing, and cool environment Encouraged to have adequate To promote cooling surface To replace fluid loss due to body heat Heat is loss by evaporation and conduction After 4 hrs. Of nursing interventions, the patient was able maintain core temperature within normal range. Goal met. Monocytes Pyrogenic cytokines Anterior hypothalamus Elevated thermoregulatory set point To reduce metabolic 40

Restlessness V/S taken as follows: T: 38.6 C P: 78 R: 19 BP: 110/80 Increased Heat bed rest Dependent: conservation(Vasoconstriction/behaviour chang es) Increased Heat production (involuntary muscular contractions) Administered P aracetamol as ordered Administered IVF as ordered demands To decrease temperature F EVER To support circulating volume and tissue perfusion CUES Subjective: Palagi akong NURSING DIAGNOSIS Diagnosis: Risk for deficient SCIENTIFIC KNOWLEDGE Recognition of dengue viral antigen PLANNING Short Term: After 1 hr. of nursing NURSING INTERVENTION Independent: > Note possible conditions like RATIONALE >These conditions may lead to fluid EVALUATION Short term: Goal Met. 41

nauuhaw, as verbalized by the patient Objective: > Decreased platelet count= 69L >Thirst >Weakness fluid volume related to decreased blood volume secondary to altered platelet pro duction Definition: The state in which an individual is at risk of experiencing vascular, cellular, or intracellular dehydration on infected monocyte by cytotoxic cells Cellular direct destruction Infection of red bone marrow precursor cells Immunological platelet survival Platelet lyses Hemorrhage Increasing the risk for fluid volume deficit interventions, the client will be able to demonstrate behaviors that reduce the risk of decreased fluid volume as manifested by: > > Increased oral Enumerate wa ys fluid intake. to prevent bleeding fluid loss and limited intake. > Monitor I&O deficits >To ensure accurate picture of fluid status >Water loss can directly af fect the body system >The GI tract is the most usual source of bleeding of its m ucosal fragility > Monitor VS changes. > Assess the signs and symptoms of GI bleeding. Check for secretions. Observe color and consistency of stools or vomitus. > Observe for pr esence of petichiae, ecchymosis, bleeding from one more sites. > Encourage use o f soft toothbrush. Avoid straining in stool, and forceful nose blowing. After 1 hour of nursing interventions, the client was able to demonstrate behavi ors that reduce the risk of decreased fluid volume. .> Increased oral fluid inta ke. > Enumerate ways to prevent bleeding >Su-acute disseminated intravascular coagulation may develop seondary to altered clotting factor >Minimal trauma can cause mucosal bleeding 42

> Monitor lab studies ( Hb,Hct, RBC count, platelet, PTT, APTT) > Encourage wate r for thirst instead of juices or soda.. > Promote intake of high-water content foods (e.g. popsicles, gelatin, eggnog, watermelon) >Aids in establishing blood replacement needs & monitoring effectiveness of ther apy. >Juices or soda are more concentrated and has lesser water content. >Adds w ater in the diet without overwhelming the client with bulk of drinking water. Collaborative: > Provide/ assist in >To replenish fluid volume for severe giving dehydration supplemental fluids as indicated (e.g. parenteral, enteral) VI. DISHARGE PLANNING METHODS MEDICATION: 43

Continue taking prescribe medication for the patient on exact dosage, time, and frequency making sure that the purpose of the medication is truly discussed by t he health care provider. Instruct the patient to follow the instruction when adm inistering meds. Advice the significant others not to leave the patient during m eds. Advice the patient not to stop intake of prescribed meds, unless approved b y the physician. Don't give aspirin and NSAID's, they increase the risk of bleeding. Any medicines that decrease platelet count should be avoided. EXERCISE: Instruct to avoid excessive activities that may result to stress. Just advised to perform range of motions and repetitive body movements for promotion of optimum health. Remind about the need for health promotion activities such a s reading, watching T.V, etc. TREATMENT: Bed rest is advisable during the re-occ urrence of fever phase. Instruct to drink plenty of water or fluids that are ava ilable at home and eat nutritious diet. Advised to look for re-occurrence of dan ger signs and symptoms and report immediately. HYGIENE: Encourage to continue the routinely hygienic care of the patient 44

OPD: Instruct the family members to have a check-up or to consult physician once a while to monitor patient's condition and for detection of recurrences and other complications that may arise on to it. DIET: Instruct the family members to giv e the client protein rich foods such as meat, fish, eggs and dairy products. VII. CONCLUSION As part of our requirement, we had learned so much in handling our cl ient who DHF. We attained and follow certain standards and rules to promote nurse patient interaction. With this case study, we gain knowledge that we can s urely use in the future ahead. All we do to our client is the summary of what we have learned in lectures in school. We also share some information with our cli ent like the main probable cause and the risk factors of having DHF. We do manag e our time to give sufficient care to our beloved client. We believed that clien t is our work and we have the responsibility to attend to their needs and serve them as best as we can. We are able to provide health teaching about the proper health care to our client with DHF. We started having an interview by building t rust to our client because at first, he wasn't like to share some information to u s. But, as time goes by, we were able to let our client share some information t hat will be very useful in this case studies. VIII. BIBLIOGRAPHY Schull, Dwyer P atricia, Nursing Spectrum DRUG Handbook, The McGraw-Hill Companies, Inc. copyrig ht 2008 Wilkinson, Judith M, and Nancy R. Ahern, Nursing Diagnosis Handbook 9th edition, Pearson Education South Asia Pte. Ltd copyright 2009 45

Kozier, Barbara; Avory Berman; Glenora Erb and Shirlee Snyder, Fundamentals of N ursing 7th Edition, Pearson Education South Asia Pte. Ltd. Copyright 2004 Colber t, Bruce J; Jeff Ankney and Karen T. Lee, Principles of Anatomy & Physiology, an interactive journey, Pearson Education South Asia Pte. Ltd. Copyright 2007 Walk er, Richard Guide to the HUMAN BODY, Octopus Publishing Group Ltd. Copyright 200 3 Delaune, Sue E. and Patricia K. Ladner, Fundamentals of Nursing, Standards and practice, 3rd edition, Thomson learning Asia,Copyright 2006 Nursing 2006 Drug ha ndbook 26th edition, Lippincott Williams and wilkins Deglin, Judith Hopper and A pril Hazard Vallerand, Davis's Drug Guide for Nurses, 9th edition Nurse's Pocket Gui de: Nursing diagnoses with interventions 4th edition Brunner & Suddarths, Medica l and Surgical Nursing 10th edition, Lippincott Williams & Wilkins Copyright 199 6 46