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Christ the King CollegeNursing Program

Gingoog City

“Dengue (break-bone fever)”

A Case Study on the Concept of Infectious Diseases:In partial fulfillment for the midterm requirement of NCM 107

(Related Learning Experience)

Submitted toMrs. Emily C. Albacete, RN

Clinical Instructor

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Submitted byLeilani Rodriguez-Ampo

Bachelor of Science in Nursing – IV

DateJanuary 27, 2012

Table of Content

I. Objectives &Introduction

II. Personal Information Data

III. Developmental Data

IV. Assessment

V. Anatomy and Physiology

VI. Pathophysiology

VII. Nursing Care Plans

VIII. Drug Analysis/Study

IX. Discharge Planning

X. Diet Analysis

XI. Prognosis

XII. Evaluation

XIII. Recommendation

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XIV. References

XV. Appendices

General Objective

This case presentation aims to identify and determine the general health

problems and needs of the patient with an admitting diagnosis ofSystemic Viral

Illness R/I Dengue Fever. This presentation also intends to help patient promote

health and medical understanding of such condition through the application of the

nursing skills.

Specific Objectives

To raise the level of awareness of patient on health problems that he may

encounter.

To facilitate patient in taking necessary actions, to solve and prevent the

identified problems on his own.

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

the health workers.

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To render nursing care and information to patient through the application

of nursing skills.

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

Introduction

This epidemic disease, which occurs in tropical areas, is caused by a virus

that is usually transmitted by a mosquito (aedesaegypti). It is rarely seen in the

United States. After an incubation period of five to seven days, symptoms appear

suddenly with high fever up to 106*F (41*C), flushed face, headache, painful

eyeballs, sorethroat, nervousness, disturbed sleep, and severe pain in the head,

back, and joints (hence the term breakbone). Prostration may be great.

About the third or fourth day the temperature usually drops to normal, only

to recur after about three days. The second wave of illness is usually less severe

and shorter in duration, and is accompanied with a rash on the hands and feet

that spreads to arms, legs, and body. The acute symptoms soon end. Usually the

disease is self-limited, but convalescence is slow.

There is no specific treatment, and deaths from the disease are almost

unknown. Good nursing is important. Bed rest and drinking an abundance of

water are essential. Cool enemas and tepid baths will lower the temperature

should it rise above 104*F (40*C). An ice bag to the head usually feels good.

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Personal Information Data

Name: Charlemagne B. Dime

Age: 14 years old

Sex: Male Child

Nationality: Filipino

Religion: Roman Catholic

Parents: Mr. and Mrs. Gregorio Dime

Address: Purok 3 North Poblacion, Medina, Misamis Oriental

Date admitted: January 01, 2012

Time admitted: 10:15 AM

Chief complaints: Fever x 2 Days

Admission Impressions: Systemic Viral Illness R/I Dengue Fever

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Attending Physician: Dr. Harold R.Cagang

Vital signs:

Temperature: 38.8 C

Heart Rate: 90bpm

Respiration Rate: 24cpm

Weight: 57 kgs.

Developmental Data

Freud’s Psychosexual Stage :Genital stage: Adolescent

develops sexual maturity and learns to establish satisfactory

relationships with the opposite sex.

Nursing Implications:The client said he is a typical teenager

who loves to explore opposite sex relationship, fond of going out after school and

have fun at the recreational areas with friends of the same age.

Erikson’s Developmental Task:Erikson believed the new

interpersonal dimension that emerges during adolescence is a

sense of identity versus role confusion.

Nursing Implication: According to the client he is well

provided with love and care by his parents. He is being

supported and praised for any decision making he does or any feelings he

discussed about events important to him which makes him sure of himself as a

person.

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Piaget’s Cognitive Development:Piaget saw adolescence

as the time when cognition achieves its final form, that of

formal operational thought.

Nursing Implication: The client expresses worry of his

illness because he is aware of the possibility of fatality with

this disease if left untreated and unattended.

Assessment

Family History:

Client was born second to the oldest among three siblings. The family has

no health problems, except the mother is currently being monitored with her

“Hypertension” which is induced due to her fourth pregnancy. However,

Charlemagne is the first in the family being brought to hospital for such illness.

Disease History:

One day prior to his admission, the client said he was gallivanting at the

neighbor’s place last December 31, 2011 (Saturday), and was caught by the rain.

When he reached home he was having chills and hyperthermia. His parents

decided to bring him to hospital since he was vomitus and having chills and

fever.

Physical Assessment Tool:

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Neurologic System

The patient was lethargic during admission as observed by NOD.

Digestive System

The abdomen was not distended, soft and there was no palpable mass

upon palpation. Hyperactive bowel sound heard upon auscultation. The patient

vomited once prior to admission.

Respiratory system

His respiratory pattern is not in regular range for his age as evidenced by

his respiratory rate of 25cpm. His breath is having tachypnea because it is faster

than 20 breaths per minute.

Cardiovascular system

His apical pulse is 90bpmand his radial pulse is 88 bpm. His heart sounds

are normal. There are no murmurs heard in the apical pulse upon inhalation and

exhalation.

Musculoskeletal System

The patient manifested good posture and moved voluntarily; he had

symmetrical musculature on both sides of the body. Weakness was noted and

client is complaining of muscle pains and joint pains.

Genito-Urinary System

Patient voided 60-250 cc per shift as monitored through I&O, and yellow in

color as verbalized by the client.

Integumentary System

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Thick and curly distributed hair was noted. His nails were convex shape,

smooth in texture, capillary refill of 2 seconds of an untrimmed finger nails with

sweaty palms. His skin was flushy red, warm to touch and fare complexion.

HEENT

The size of the head was in proportion with the body. The eyes were

symmetrical with ears; with painful red eyes (Conjunctival suffusion). When the

eyes were tested papillary reaction to light, the pupil constricted to 2mm. Ear had

no discharges noted. Patient’s throat was functioning well and in normal

condition.

Activity

The patient canmove his extremities but with joint pains and muscle pains.

Hecan move and walkwithout assistance and was given comfort room privileges.

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

the hospital confinement.

Sleep and rest

He usually sleeps at 8:00 pm and rise at 6:00 am. Sometimes his sleeping

pattern is only disturbed when he is not feeling well. The patient feels different

about himself since his hospitalization because of many restrictions imposed by

thehealth care team plus the uncomfortable condition of the IV fluids attached to

his arm and the muscle and jointpains that is disturbing his comfort to sleep.

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Values and Beliefs

The client’s family goes to Catholicchurch every Sunday and believes in

every celebration of Christmas Eve, New Year’s Day, Lenten season and Easter

Sunday.

Physical Examination

DATE

1-01-12

Vital sign

7-3 3-11 11-7

Temperature 38.8C 38.7C 38.2C

Pulse rate 90bpm 98bpm 100bpm

Respiratory rate 24cpm 25cpm 22cpm

A. Skin- warm, flushed red, fair in complexion, with sweaty palmsB. Nails- pallor nail bed, dirty with fine capillary refill (approximately within 2

seconds)C. Head/ face -no mass palpated, flushed faceD. Scalp- thick curly hair evenly distributed with no dandruff or lesions

observedE. Eyes- with red sore conjunctival suffusion, no discharges noted, pupils

are equally round and reactive to light and accommodationF. Ears- symmetrical with cerumen, no discharges notedG. Nose-no flaring of nostrils, no discharges notedH. Mouth-dry mucous membranes and pale lips

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I. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and pain

J. Chest and Lungs- without crackles and ronchiK. Abdomen- soft, not distendedL. Extremities- weak extremities, muscle and joint painsM. GIT- loss of appetiteN. Renal and Urologic changes-decrease urine output(<30ml/hr)O. Cardiovascular changes- noneP. Hematopoietic changes – none

DATE

1-02-12

Vital sign

7-3 3-11 11-7

Temperature 37.8 C 37.2C 38.1 C

Pulse rate 100bpm 110bpm 92bpm

Respiratory rate 29cpm 30cpm 24cpm

A. Skin- warm, flushed red, fair in complexion, with sweaty palmsB. Nails- pallor nail bed, dirty with fine capillary refill (approximately within 2

seconds)C. Head/ face -no mass palpated, flushed faceD. Scalp- thick curly hair evenly distributed with no dandruff or lesions

observedE. Eyes- with red sore conjunctiva suffusion, no discharges noted, pupils are

equally round and reactive to light and accommodationF. Ears- symmetrical with cerumen, no discharges notedG. Nose-no flaring of nostrils, no discharges notedH. Mouth-dry mucous membranes and pale lipsI. Neck- no mass palpated, without lesions, no enlargement of lymph nodes

and painJ. Chest and Lungs- without crackles and ronchiK. Abdomen- soft, not distendedL. Extremities- weak extremities, muscle and joint painsM. GIT- loss of appetiteN. Renal and Urologic changes-decrease urine output(<30ml/hr)

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Interpretation:

Platelets is lower than normal range which would risk for bleeding tendency and

coagulation problems or hemolysis.

Lymphocytes is lower than normal range which might need help in fighting against

infection. Indicates decrease immune system.

Segmenters indicates high glucose level in the blood.

O. Cardiovascular changes- noneP. Hematopoietic changes – none

Diagnostic and Laboratory Results

Date: January 01, 2012 Time: 10am

Complete Blood Count

Result Normal Value

White Blood Cell 5,900 4.5 – 11.0 X 10/mm

Hemoglobin 14.4 Fem- 11.7 – 14.5 g/dl

Male-13.7- 16.7 g/dl

Hematocrit 42.0 Fem-34.1-44.3 vol %

Male-39.3-48.0 vol %

Platelet 115,000 175,000-350,000/mm

Segmenters 86 45-70%

Lymphocytes 11 18-45%

Monocytes 03 3-8%

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Diagnostic and Laboratory Results

Date: January 02, 2012 Time: 10am

Complete Blood Count

Result Normal Value

White Blood Cell 3,200 4.5 – 11.0 X 10/mm

Hemoglobin 15.9 Fem- 11.7 – 14.5 g/dl

Male-13.7- 16.7 g/dl

Hematocrit 47.9 Fem-34.1-44.3 vol %

Male-39.3-48.0 vol %

Platelet 106,000 175,000-350,000/mm

Segmenters 84 45-70%

Lymphocytes 14 18-45%

Monocytes 02 3-8%

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Interpretation:

Platelets rapidly drops more lower than normal range which would risk for bleeding

tendency and coagulation problems or hemolysis.

Lymphocytes is lower than normal range which might need help in fighting against

infection. . Indicates decrease immune system

Segmenters indicates high glucose level in the blood.

WBC a decrease value indicates inadequate inflammatory defenses to suppress

infection and humoral immunity takes place.

I. Anatomy and Physiology of the Blood

ANATOMY AND PHYSIOLOGY

The Immune System A second line of defense is

housed within the body: a finely

tuned immune system that

recognizes and destroys foreign

substances and organisms that

enter the body. The immune

system can distinguish between

the body's own tissues and

outside substances called

antigens. This allows cells of the

immune army to identify and

destroy only those enemy

antigens. The ability to identify an

antigen also permits the immune

system to "remember" antigens

the body has been exposed to in

the past; so that the body can

mount a better and faster immune

response the next time any of

these antigens appear.

The immune system also includes

other proteins and chemicals that

assist antibodies and T cells in their work. Among them are chemicals that alert

phagocytes to the site of the infection. The complement system, a group of

proteins that normally float freely in the blood, move toward infections, where

they combine to help destroy microorganisms and foreign particles. They do this

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by changing the surface of bacteria or other microorganisms, causing them to

die.

Enzyme(EN-zime) is a protein that helps speed up a chemical reaction In

the body.

Antigens(AN-tih-jens) are substances that are recognized as a threat by

the body's immune system, which triggers the formation of specific

antibodies against the substance.

Bone marrow is the soft tissue inside bones where blood cells are made.

Lymphatic(lim-FAH-tik) system is a system that contains lymph nodes

and a network of channels that carry fluid and cells of the immune system

through the body.

Immunity(ih-MYOON-uh-tee) is the condition of being protected against

an infectious disease. Immunity often develops after a germ is introduced

to the body. One type of immunity occurs when the body makes special

protein molecules called antibodies to fight the disease-causing germ. The

next time that germ enters the body, the antibodies quickly attack it,

usually preventing the germ from causing disease.

Primarily, the immune system classifies a substance as:

a. Self-non-foreign – they are normally ignored and tolerance and is

exhibited towards these substances. They are not deemed harmful.

b. Non-self – termed as an “antigen”; a specific response is developed to a

specific antigen. The response is then stored in the immune system’s

memory cells for future reference.

Components of the Immune System:

1. Lymphoid Structures Spleen

- Composed of red and white pulp, acts somewhat like a filter.

- The red pulp is the site where old and injured red blood cells are

destroyed.

- The white pulp contains concentrations of lymphocytes.

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Lymph Nodes- Are distributed throughout the body

- Are connected by lymph channels and capillaries, which remove

foreign material from the lymph before it enters the bloodstream.

2. Immune Cells – Lymphocytes

a. B lymphocytes (or B cells) - produce immunoglobulins.

b. T lymphocytes (or T cells) - help control the immune response and

destroy foreign antigens directly.

c. Plasma Cells - are white blood cells that produce large volumes of

antibodies.

3. Tissues – The remaining lymphoid tissues, such as the tonsils and

adenoids and other.

Mucoid Lymphatic Tissue – contain immune cells that defend the

body’s mucosal surfaces against microorganisms.

Types of Immune Defense:a. Innate or Nonspecific Immunity

- Also termed as the person’s natural resistance, and are the most

basic and primary of all defenses in the body. (skin, mucus

membranes, phagocytic activity)

4. Immune Cells – Lymphocytes

d. B lymphocytes (or B cells) - produce immunoglobulins.

e. T lymphocytes (or T cells) - help control the immune response and

destroy foreign antigens directly.

f. Plasma Cells - are white blood cells that produce large volumes of

antibodies.

5. Tissues – The remaining lymphoid tissues, such as the tonsils and

adenoids and other.

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Mucoid Lymphatic Tissue – contain immune cells that defend the

body’s mucosal surfaces against microorganisms.

2 Types of Immunity Active – acquired through previous exposure of the disease or through

immunization wherein the body “actively” participates in formation of

antibodies for future reference.

Passive – refers to whole, “ready made” immunity acquired from another,

the body is just “passive” in the process of developing antibodies, as it is

already made and given readily.

4 Types of Active Immunitya. Humoral Immunity

b. Mucosal Immunity

c. Cell-mediated Immunity

d. Delayed HypersensitivityReaction

Antibodies or Immunoglobulins – developed from B-cells through the stimulation

of cytokines produced by helper T-cells in the presence of an antigen. They

attach to specific determinant sites on antigens, and carries out phagocytosis

and initiating inflammation.

IgG 75% Crosses placental barrier; present in circulation and tissue

spaces; antiviral, antitoxic and anti-bacterial properties;

activates complement

IgA 15% Found in body secretions and breast milk; protects mucous

membranes from microorganisms

IgM 10% Forms natural ABO antibodies; present in early immune

responses; activates complement

IgE .2% Hypersensitivity reaction mediator; Involved in parasitic

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infectious

IgD .004% Necessary for maturation of B lymphocytes

Hematologic SystemTwo types of blood vessels carry blood throughout our bodies:

1. Arteries carry oxygenated blood (blood that has received oxygen from the

lungs) from the heart to the rest of the body.

2. Blood then travels through veins back to the heart and lungs, where it

receives more oxygen.

The blood that flows through this network of veins and arteries is whole blood,

which contains three types of blood cells:

1. Red blood cells (RBCs) - (also called erythrocytes) are shaped like slightly

indented, flattened disks. RBCs contain the iron-rich

protein hemoglobin. Blood gets its bright red color when

hemoglobin picks up oxygen in the lungs. As the blood

travels through the body, the hemoglobin releases

oxygen to the tissues.

- The body contains more RBCs than any other type of cell, and each has a

life span of about 4 months. Each day, the body produces new RBCs to

replace those that die or are lost from the body.

2. White blood cells (WBCs) - (also called leukocytes) are a key part of the body's

system for defending itself against infection. They can

move in and out of the bloodstream to reach affected

tissues. Blood contains far fewer WBCs than red blood

cells, although the body can increase WBC production

to fight infection. There are several types of WBCs, and their life spans

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vary from a few days to months. New cells are constantly being formed in

the bone marrow.

- Certain types of WBCs produce antibodies, special proteins that recognize

foreign materials and help the body destroy or neutralize them. The white

cell count (the number of cells in a given amount of blood) in someone

with an infection often is higher than usual because more WBCs are being

produced or are entering the bloodstream to battle the infection.

3. Platelets- (also called thrombocytes) are tiny oval-shaped

cells made in the bone marrow. They help in the

clotting process. When a blood vessel breaks,

platelets gather in the area and help seal off the

leak. Platelets survive only about 9 days in the

bloodstream and are constantly being replaced

by new cells.

- Platelets and clotting factors work together to form solid lumps to seal

leaks, wounds, cuts, and scratches and to prevent bleeding inside and on

the surfaces of our bodies. The process of clotting is like a puzzle with

interlocking parts. When the last part is in place, the clot happens — but if

even one piece is missing, the final pieces can't come together.

Pathophysiology of Dengue Fever

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Predisposing PrecipitatingGeographical area-Tropical islands Environmental conditionsIn the Philippines (Asia Pacific)Immuno-compromise

Mosquito carrying dengue virus Soldier, Students

Sweaty skin

AedesAegypti (dengue virus carrier) 8-12 days of viral replication on mosquitoes salivary glands.

Bite from mosquito (portal entry in the skin)Redness & itchiness

Allowing dengue virus to be inoculated towardsthecirculation/blood(Incubation Period: 3-14 days)

Virus disseminated rapidly into the bloodand stimulatesWBCs including B-lymphocytes that produces and

secretesimmunoglobulins (antibodies), andmonocytes, macrophages, neutrophils

Diagnostic Hematology:WBC 12,900/cumm (5,000-10,000)Lymphocytes 49% (20-40%)

Antibodies attach to the viral antigens, and thenmonocytes/macrophages perform phagocytosis through Fc receptor w/in the cells

and dengue virus replicates in the cells.Entryto Spleen

Diagnostic hem: Monocytes:42%Neutrophils 49%

Entry to Bone

Recognition of dengue antigen on infected monocyte

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

Signs/Symptoms:Febrile:38.6*CDiaphoresis,warm skin,flushed,Headache of 3/10pain scaleDengue

Narrative PathophysiologyofDengue Fever

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Dengue fever is a severe potentially deadly infection spread by

AedesAegypti mosquitoes through salivary glands that enters human skin portals

(biten). Dengue virus inoculates in blood circulation and incubates within 3-14

days.Virus disseminated rapidly into the blood and stimulatesWBCs including B-

lymphocytes that produces andsecretes immunoglobulins (antibodies),

monocytes, macrophages, and neutrophils. At this stage, there will be an

increase of WBCs and Lymphocytes. Antibodies attach to the viral antigens, and

thenmonocytes/macrophagesperform phagocytosis through Fc receptor within

the cellsand dengue virus replicates in the cells. Replicated virus cells will then

enter the Spleen and Bone Marrow. Within this period the monocytes and

neutrophils will decrease. Dengue viral antigen will be recognized on the infected

monocyte. Release of cytokines will stimulate WBCs and the release of

pyrogensA manifestation of hyperthermia, diaphoresis, warm skin, flushed face,

and headache is usually shown. Virus attacks liver and spleen and causes cell

death and other complications such as intense bleeding, pulmonary edema,

shock, liver cirrhosis or death.

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NURSING CARE PLANNursing Diagnosis:

Hyperthermia related to illness, exposure to viral/bacterial environment.Cause Analysis:

Pyrexia is common if inflammation is extensive. If fever infection has caused inflammation, fever can be severe depending on particular microorganism. Fever results from the release of pyrogens.

CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective:“Gitakiganko, ugtaasakohilanat, nagsakitakoulogikangahapon”, as verbalized by the patient.

Objective:Flushed skinFever: 38.8*CDiaphoresisRed EyesInc. Resp. RateChillsHeadacheDec. platelet count

LTO:

At the end of 2 days intervention the patient will be able:

torecover from decreasing platelet count.

STO:

At the end of 8 hours intervention the patient will be able to:

Maintain body temperature below 37.8*C

Independent:

1. Determine precipitating factors.

2. Assess vital signs especially tympanic or rectal temps.

3. Provide fluids by mouth.

4. Provide cold packs and tepid sponge bath.

Collaborative:

1. Identification and management of underlying cause are essential to recovery.

2. To provide accurate core temperature.

3. to decrease warmth and increases evaporative cooling.

4. topromote cooling & lowering temp.

1.To prevent cellular damage, delirium, and convulsions.

After series of intervention the patient:

Was not yet relieved of fever thoroughly.

Platelets rapidly decreases and patient was transferred for a tertiary care.But patient is relieved w/ fever after immediate interventions given.

-Goals are met partially-

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1. Provide antipyretic medications PRN

NURSING CARE PLANNursing Diagnosis:

Acute Pain related to biological factors such as activity of disease process.

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Cause Analysis: Fever infection has caused inflammation, fever can be severe depending on particular microorganism. Fever results from the release of pyrogens. And causes cell destruction, pain in the body parts and other complications.

CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATIONSubjective:“Sakit kayo ulo,akomata, mgabukogug muscles”, verbalized by the client.

Objective:Flushed skinFever: 38.8*CDiaphoresisRed EyesInc. Resp. RateChillsHeadacheDec. platelet countBody malaiseJoint painsMuscle pains

LTO:

At the end of 3days intervention the patient will be able:

torecover from muscle and joint pains.

STO:

At the end of 8 hours intervention the patient will be able to:

verbalize adequate relief of pain or ability to cope with incompletely relieved pain in the muscle & joints& head.

Independent:

1. Assess pain noting location, duration, intensity.

2. Encourage increase fluid intake.

3. Provide comfort measure such as use of heat/cold packs, repositioning, quiet environment .

4. Investigate results of platelet count.

Collaborative:1. Administer

antipyretic medications PRN/ antibacterials/antivi

1.To provide information and determine interventions.

2.To flush bacteria and toxins and regulate body temperature.3.To provide relaxation and refocuses attention from pain and enhance coping mechanism.4. indication of Dengue fever infection at risk.

1. Reduces pain, fever, and infections that is affecting body system of the patient.

After series of intervention the patient:

Was not yet relieved of on and off 3 days fever. Platelets rapidly decreases and patient was transferred for a tertiary care.However patient is relieved w/ headache through cold packs.

-Goals are met

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rals if prescribed.

NURSING CARE PLANNursing Diagnosis:

Imbalanced Nutrition: less than body requirements related to inability to ingest food.Cause Analysis:

Intake of nutrients insufficient to meet metabolic needs.CUES OBJECTIVES NURSING RATIONALE EVALUATION

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INTERVENTIONSSubjective:“Dilinako kaya magtulonpagkaon, busogpermeakotiyan,makasukako”, as verbalized by the client.

Objective:AnorexiaFever: 38.8*CVomitusChillsBody malaise/weaknessFatigue

LTO:

At the end of 3days intervention the patient will be able:

todemonstrate progressive weight gain and strength.

STO:

At the end of 8 hours intervention the patient will be able to:

verbalize relief from Anorexia.

Independent:

1. Assess Causative factor for malnutrition.

2. Determine client’s ability to chew, swallow, and taste food. Evaluate teeth and gums for poor oral health, note gum bleedings.

3. Prevent unpleasant odors/sights.

4. Promote pleasant relaxing environment including oral care before and

1.To determine how to meet metabolic needs of patient.

2.All factors can affect ingestion and or digestion of nutrients.

3.This may have a negative effect on appetite/eating.

4. To enhance food intake.

1. To reduce possibility of early satiety.

2. To stimulate

After series of intervention the patient:

Was able to improved his nutrition intake by taking fruit juices and slowly taking hot soups brought to him.-Goals are met

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after meals.

Collaborative:1. Promote

adequate/ timely fluid intake. Limit fluids 1 hour prior to meal.

2. Encourage use of lozenges.

salivation when dryness is a factor.

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DRUG STUDYDate Ordered: January 01, 2012

Name of Drug Classification

Why Given to Patient in Relation to the Mechanism of Action

Contraindication Side Effect Nursing Consideration

Generic (Brand)Apap,paracetamol Acetaminophen

Dose/Frequency Prescribed500mg 1tab q 4 for PRN T>38.8*C.

Recommended Dose and FrequencyUsual starting dosage based on patient response. Maximum dose, 640 mg/day PO q 4* to 6* PRN.

Therapeutic:Nonopioid Analgesics and Antipyretics

Pharmacologic:Para-aminophenol derivatives

Stability of the Drug:Stored in a room temperature

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

Hypersensitivity to drugs.

IndicationTreatment of mild pain or fever.

Stimulation, drowsiness, nausea, vomiting, abdominal pain, hepatotoxicity, seizure, renal failure, hemolytic anemia, CNS stimulation, delirium, vascular collapse, convulsions, coma, death.

Assess patient’s type of pain, location, intensity, duration, temp., diaphoresis.Assess allergic reactions: rash,urticariaAssess for chronic poisoning: rapid pulse, weak pulse, dyspnea,coldclummy skin, report immediately.

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Discharge Planning

Medication

Intake of appropriate vitamin supplement and diuretics to increase protection mechanism of the immune system and decreases renal vascular resistance and may increase renal blood flow, respectively.

Economic

The use of nonpharmaco therapy such as drinking plenty of water will promote increase plasma in blood to increase immunity and proper hygiene and promotion of cleanliness at home and work area.

Treatment

Management of such condition would be through hydration and doing control measures to eliminate vector by promoting cleanliness in the environment through proper disposal of rubber tires, changing of water of lower vases once a week, destruction of breeding places of mosquito and residual spraying with insecticides.

Hygiene

Advise to follow proper body hygiene and to maintain cleanliness on surroundings. This would prevent additional cases of DHF.

Out Patient/ Follow-up

Any odd signs such as fever, petechiae, recurrence of fever, must be immediately reported to the physician.

Diet

Instruct to eat no dark colored foods or hemoglobin free diet that can interfere test for stools.

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Diet Analysis

Patient having dengue fever must have to follow a normal diet or diet as

tolerated to foster wasting of nutrient which the patient has loss during the

sickness.

The importance of why the patient ordered to have a “No dark colored

food or hemoglobin free diet” is to prevent interference during stool exam results.

It is safe to serve Cheese, milk, eggs, non-leafy vegetables, refined

vegetables, fruits and fruit juices.

Avoid alcoholic and acidic beverages that may irritate the GIT and

stimulate vomiting. Instruct patient to eat foods that are low fat, low fiber, non-

irritating and non-carbonated.

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Sample Diet for One Day

Breakfast: 6:00 – 7:00

Papaya

Fried vegetarian tocino

Boiled camote

Unpolished rice

Warm milk

Lunch: 11:45 – 12:15

Low salt boiled camote tops

Unpolished rice

3 ounces sliced turkey

1 lettuce leaf

1/2 cup cucumber salad

1 medium apple

Evening Meal: 6:30 – 7:00

3 ounces broiled fish

1/2 cup rice

1/2 cup green beans

1 cup lettuce salad

2 teaspoons margarine

1 cup lemon water

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Prognosis

Typical dengue is fatal in less than 1% of cases. The acute phase of the

illness with fever and myalgias lasts about one to two weeks. Convalescence is

accompanied by a feeling of weakness (asthenia), and full recovery often takes

several weeks.

The prognosis is good as long as the client complies to proper

medications, proper nutrition, adequate hydration and proper hygiene. The

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

arises.

CRITERIA FOR PROGNOSIS BASING FROM THE FOLLOWING

A. Age Good

B. Onset of Illness Poor

C. Duration of Illness Poor

D. Nature of Illness Moderate

E. Support System Good

F. Financial Support Good

G. Compliance of Treatment Good

Evaluation

32

The patient in this study had undergone supportive and symptomatic

management. He was admitted last January 01, 2012 at MOPH-Gingoog Cityand

was eventually transferred to Cagayan de Oro City last January 03, 2012 for a

tertiary care due to rapidly dropping platelets caused by Dengue Fever Virus.

Proper nursing care such as water therapy and administration of prescribed

drugs were done to promote comfort and repression of symptoms. Hygiene was

also strictly implemented to avoid risk for further infection. Nursing assistance

was also given to help him in his activities of daily living.

Health teaching is a very important role on the part of the nurses. This is of

great significance to the knowledge deficit of patients regarding health and

illness.

Recommendation

33

Strict compliance to the medical treatment, health teachings and medical

check-up is advised. With proper nutrition and conformity to the medications &

therapy, recovery would be easier and faster.

There is no specific treatment for classic dengue fever, and like most people

you will recover completely within 2 weeks. To help with recovery, health care

experts recommend:

Getting plenty of bed rest

Drinking lots of fluids

Taking medicine to reduce fever

Often health care provider advises people with dengue fever not to take

aspirin. Acetaminophen or other over-the-counter pain-reducing medicines are

safe for most people. For severe dengue symptoms, including shock and coma,

early and aggressive emergency treatment with fluid and electrolyte replacement

can be lifesaving.

The best way to prevent dengue fever is to take special precautions to avoid

contact with mosquitoes. Several dengue vaccines are being developed, but

none is likely to be licensed by the Food and Drug Administration in the next few

years.

34

When outdoors in an area where dengue fever has been found

Use a mosquito repellant containing DEET, picaridin, or oil of lemon eucalyptus

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

Because Aedes mosquitoes usually bite during the day, be sure to use

precautions especially during early morning hours before daybreak and in the

late afternoon before dark.

Other precautions include:

Keeping unscreened windows and doors closed

Keeping window and door screens repaired

Getting rid of areas where mosquitoes breed, such as standing water in

flower pots, containers, birdbaths, discarded tires, etc.

References

35

Meg Gulanick, Nursing Cared Plans, 6th edition, copyright 2007

Jean ForetGiddenset. al., Mosby PDQ for RN, 2nd edition, copyright 2008

Joyce M. Black et. al., Medical Surgical Nursing, 8th edition, copyright

2009

Barbara E. Gould, Pathophysiology for the Health Profession, 3rd edition,

copyright 2006

Judith A. Schilling McCann et. al., Nursing 2007 Drug Handbook,

copyright 2006

Sue E. Huether, Understanding Pathophysiology, 4th Edition, copyright

2008

Barbara C. Long, Medical Surgical Nursing, 3rd Edition, copyright 1993

Saul Kassin, Psychology, 2nd edition, copyright 1998

Camille B. Wortmanet. al., Psychology, 3rd Edition, copyright 1988

Amy M. Karch, Focus on Nursing Pharmacology, 4th Edition, copyright

2008

AppendicesAnnex -A

36

Christ the King CollegeNursing Program

Gingoog CityKardex

Name of Student: Leilani R. Ampo Year Level: 4 th year BSN Date of Duty: January 3, 2012

Last name: First name: Middle name:Dime, Charlemagne BalisryAge:14 year old

Sex:Male

NationalityFilipino

Religion:Roman Catholic

Civil Status Child

Room/Bed #:207(annex)

Address: Purok 3 North Poblacion, Medina, Misamis OrientalContact Number:

Chief Complaints: Fever X 2 days

Date admittedJan. 01, 2012

Time admitted:10:15 AM

Attending Physician:Dr. Harold R. Cagang

Hospital #27-70-58

Medical record # #5

Admission Impressions:Systemic Viral Illness R/I Dengue FeverPrognosis: Good prognosis as long as client complies with medication, have proper nutrition, maintains proper hygiene and oral fluid intake. Andfamily can afford for a tertiary care hospitalization if complication arises.

Area of Duty:MOPH-Gingoog (Annex Bldg. Medical Ward)

Date Medication Remarks Date Ordered

Time I.V. Fluids RemarksTime on

Time Consumed

1-1-12 Paracetamol 500 mg 1-1-12 Dƽ 0.3 Nacl @

37

20 gtts/min1 tab q 4º PRN if Dƽ NM іL @

SRT ≥ 37.8º C Dƽ NM іL @

SR

Date Ordered

Diet Remarks Date Ordered Laboratory Exams

Remarks

1-1-12 DAT 1-1-12 CBC č plt, u/a Result inNo dark colored Food 1-2-12 Rpt CBC č plt Result in

3PM1-3-12

Rpt CBC č pltRpt CBC č plt

Result in

Treatment:1-1-12 Vomited

Consent to care signedI&O q shiftRefer accordingly

1-2-12 Continue medsStill for labs

1-3-12 For tertiary referral

Vital Sign’s and I & ODate 1-1-12 1-2-12 1-3-12

Temperature: 38.8ºC 37.8ºC 38.1ºCBlood Pressure: 90/60mmHG 120/70mmHG 120/80mmHg

Heart Rate: 90bpm 88bpm 92bpmRespiration Rate: 24cpm 25cpm 24cpm

Reference: MOPH-GC card

38

Annex-B

Christ the King CollegeGingoog City

Nursing ProgramClient Data Form

Name of Student: Leilani R. Ampo Date: January 3, 2012

Year Level:4th YR BSN Group:_________ Area:MOPH-Gingoog (Annex Bldg. medical Ward)

Client’s InformationLast name: First name: Middle name:Dime, Charlemagne BalisryAge:14 year old

Sex: Male

Nationality Filipino

Religion: Roman Catholic

Civil Status Child

Room/Bed #:207(annex)

Address: Purok 3 North Poblacion, Medina, Misamis OrientalContact Number:

Occupation: Date admittedJan. 01, 2012

Time admitted:10:15 AM

Attending Physician: Dr. Harold R. Cagang

Reason for Hospitalization (client quote)Fever X 2 days

Admission Impressions:Systemic Viral Illness R/I Dengue FeverPrognosis: Good prognosis as long as client complies with medication, have proper nutrition, maintains proper hygiene and oral fluid intake. And family can afford for a tertiary care hospitalization if complication arises.

Family History (narrative)Client was born second to the oldest among three siblings. The family has

no health problems, except the mother is currently being monitored with her

“Hypertension” which is induced due to her fourth pregnancy. However,

Charlemagne is the first in the family being brought to hospital for such illness.

Personal History: (narrative)

One day prior to his admission, the client said he was gallivanting at the

neighbor’s place last December 31, 2011 (Saturday), and was caught by the rain.

39

When he reached home he was having chills and hyperthermia. His parents

decided to bring him to hospital since he was vomitus and having chills and with

fever.

Admission DataClient is from :

Home: __√_ Doctor’s Clinic; ___ School: ___ Work: ___ Other Hospital:___ Others: ___

____________________________________________________________ ______________________________

Mode of Admission: Ambulatory; _√__ Wheelchair: ___ Stretcher: ___ Others: ___

____________________________________________________________________________________________________________________________________

Accompanied by: Parents Valuables: None: _√__ With Client: ___ Given to relatives: ___

List:_____________________________________________________________________________________________________________________________________________________________________________________

Laboratory results from outside:Lipunan Hospital Inc., Jan.1, 2012, 10:00 AM

Person to notify in case of emergency :Name: Gregorio Dime (Father)Address: Medina, Misamis orientalContact #: _______________________________

40

Assessment Tool

Vital Signs Temperature: ___37.8 ° C ____________ Axilla/Oral

Pulse: _______88bpm______________ Radial/Brachial

Apical Pulse: _____90bpm__________

Respiration: ____25cpm___________

Blood Pressure: 120/70mmHg__ Standing/Sitting/Lying Time BP taken: 3:50 PM

Height: __5’2”Measured/Estimated

Weight: __57 kgs Measured/Estimated

Allergies/Sensitive to:Any Allergy to Food/Medicine/Latex/others? ___yes _√ _ no

If yes, Please specify: ________________________________

Have used Blood Products? ___yes _√ _ _no Reactions? ___yes __√ _ no

Cranial Nerve Assessment1. Cranial nerve IClient has no difficulty identifying scents and aromas.

2. Cranial nerve II Client has no visual problems.

3. Cranial nerve III Client’s pupils in both eyes have equal size and capable of following moving objects.

4. Cranial nerve IV Client can normally follow moving objects w/ both eyes.

5. Cranial nerve V Facial muscles can move, can chew normally.

6. Cranial nerve VI Eyes can move actively and roll eyes laterally.

7. Cranial nerve VII Can close eyes normally and tongue has good sense of taste.

8. Cranial nerve VIII Has good hearing sensation in both ears.

9. Cranial nerve IX No problem or difficulty of swallowing.

10. Cranial nerve X Strong muscle strength in the head, shoulders,

11. Cranial nerve XI neck, and back….

12. Cranial nerve XII Capable of controlling tongue movement.

41

SkinSkin Integrity/Condition

√intact

Rash

Lesion

Ulcer

Bruising

Scars

Burns

Describe: Petechiae seen after tourniquet test done 1-3-12________________________________________________________

IV Access

√Peripheral Left Arm

Central____________________

Color

Normal

Pale

Cyanotic

√Flushed

Mottled

Jaundiced

Temperature

√Warm

Hot

Cool

Cold

Note: 37.8 ° C 1-2-12

38.9 ° C 1-3-12

Moisture

√Normal

Dry

□ Diaphoretic

Mouth

√Pink/moist

Ulcers

Lesions

Bleeding

Lips

√Dry

Cracked

Intact

Lesions

Head Hair Describe: Client has clean hair and well kept. No infestations of lice.

Lice Dandruff Lesions Bald

Face Client face is clean, no scars, no acne found but face is flushed. Acne Scars Wounds/lesions

Eyes: Vision √No Impairment R/L Impaired R/L Blind Glass/Contact Lenses

Color Describe: Clear Yellow √Red R/L Both eyesDrainage R/L N/A

Ear

Hearing √No Impairment R/L Impaired R/L hearing Aide Others________________________________________________________________________________

Teeth

Dentures Yes√No

Caries Yes√No

Brace Yes√No

42

Cardiovascular Neck

√Flat Distended

Apical Pulse√Regular Irregular Pacemaker Type: _____________

Rate: 90 bpmHeart Sound

√Normal Abnormal

Note:____________________________________________________________________Radial Pulse

√Strong R/L Faint R/L Doppler R/L (If Applicable)Note:______________________________

Brachial Pulse Strong R/L Faint R/L Doppler R/L (If Applicable)

Pedal Pulse Strong R/L Faint R/L Doppler R/L (If Applicable)

Edema√No YesSite: ____________________________

Numbness√No YesSite: Muscle & Joint Pains

RespiratoryRetractions

√N/A Supra Clavicular Intercostal Diaphragmatic

Cough Describe:√N/A Non-productive Productive Ability to clear secretions

Yes No

Breath Sounds √Clear Adventitious: Equal

Tracheostomy Yes√NoDate inserted:_________________Date tube change: _____________

Chest tube Yes√NoLocation;__________________________

Oxygen√Room Air Nasal cannula Face Mask Trach Mask Endotracheal tube BIPAP CPAP

GastrointestinalAbdominal

√Soft Firm Rigid Distended

Tenderness√N/A YesLocation:_____________________

Constipation Yes√No

Diarrhea Yes√NoDate of last BM:___________

Appetite

43

Bowel Sounds√Present ___________Sounds/min. Absent

Feed Independently √Yes No

Nasogastric tube/gastrostomy tube Yes√NoNGT date change:_________________

Good Fair√Poor Nausea Vomiting

Chewing/ Swallowing Difficulties Yes Describe:

_________________√No _________________________

ExtremitiesUpper Lower

Fingers√Complete ______________________ Arthritis

______________________ Callus

_____________________Nails

Cyanotic Club√Dirt Cut

Arms Lesions Scars Arthritis Others Muscle pain & Joint Pain in

the arms.

Toes√Complete ______________________ Arthritis

______________________ Callus

_____________________Nails

Cyanotic Club√Dirt Cut

Legs Lesions Scars Arthritis Others Muscle pain& Joint Pain in

the legs.

Genital and Anal Male Female

Lice STI Not Applicable Catheter Hernia Others

Anus

Lice STI Not Applicable Catheter Hernia Menstruation Date started: Not Applicable

Date ended:

Others

44

Hemorrhoids STI Not Applicable

______________________________________________________________

Anus Hemorrhoids STI Not Applicable

45

Descriptive: Indicate all Observed in the diagram

46

FebrileTemperature 38.8ºC

Headache/Nausea

Red Eyes and Orbital Pain (Conjunctival Suffusion)

Poor appetite

IncreaseBreathingRate: 25 cpm

Flushed face

Sweaty Palms IVF @ Left ArmD5 NM 1L @ 20gtts/min

Long Finger Nails/Dirty

VomitusFeeling

BodyWeakness

MusclePains

Warm Skin

JointPains

PetechiaeAfter TourniquetTest

Annex-CCHRIST THE KING COLLEGE

Nursing ProgramGingoog City

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

Medication (12 R’s of medication)No medications available that can provide a cure. Treatment addresses the symptoms and it also attempts to avoid potential complications.

Non narcotic analgesic and antipyretics to decrease temperature or regulate pain.

Antibacterial/Antiviral to prevent/treat infections. Antiemetics to treat vomiting. IVF for electrolytes loss (D5LR) Avoid Aspirin because of gastritis and bleeding tendencies.

Diet Normal diet or Diet as tolerated to foster wasting of nutrient

which patient unconsciously losses during sickness. NDCF (No dark colored food) or hemoglobin free diet that can

interfere results for stools. Safe to serve: Cheese, milk, eggs, non-leafy vegetables, refined

vegetables, fruits and fruit juices.

Daily Plan of activity Rehydration w/ IVF to correct dehydration Administration of meds order Normal diet Keep sanitary environment to prevent infections & promote

healing Bath daily to prevent invasion of microorganisms Clean body & change to clean clothes daily Maintain good oral and body hygiene Exercise Increase fluids intake Regular bowel movement Clean surroundings and spray insecticides

47

Close containers when they collect water Proper garbage disposal

Follow upsHave a follow up consultation & regular check upsProper way to take body temperature at homeHave enough rest and avoid heavy strenuous activityAvoid alcoholic beverages while taking medsEmphasize importance of fluid intakeDiscuss use of antipyretics/antibiotics (overdoses can cause liver damage)Compliance to home medicationsWatch for signs and symptoms that require immediate medical attention

48

Submitted by:

Leilani Rodriguez-AmpoBSN IV

Thank You!

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