Pamantasan ng Lungsod ng Marikina J.P. Rizal St. Concepcion Uno, Marikina City
__________________________
DENGUE HEMORRHAGIC FEVER __________________________
A Group Case Study
Submitted to: Mr. Ryan E. Aliwalas, RN
In Partial Fulfillment
of the Requirement for the Course NCM 101
RLE
H-Vill Hospital
Submitted by: Gomez, Richerylle C. Gutierrez, Floren Angelie V.
Hernandez, Richelle Joy T. Hussin, Johanna Fariza T.
Ison, Sheila May H. Javier, Jayson R. Jayme, Carolyn Eleanor F.
Labide, Prima Encar T. Ladjahasan, Irish Princess A.
Lagumbay Joanne B. Lardillo, Catherine A. Lomocso, Jamielyn Kate B.
GROUP 7 AUGUST 2009
INTRODUCTION
We live in our world today where everything seems to be in a fast face.
As it is, we cannot deny that things change over or in a certain period of time. New technologies were being invented, clothes for fashion, jewelries, luxuries mode of entertainment, etc. It’s just like having a new mode of socialization, cultures, beliefs, perceptions, adaptation to life and environment. With all of these, one aspect of human being which are greatly affected and the one which we have to be most concern of would be in the side of our heath and well being.
In the Philippines there are many diseases illness arising because of environmental changes that may be caused by human activities and geographical conditions. It is considered as one of the tropical country and so disease can spread through out the country.
One example of these is disease is what we called Dengue Fever and dengue Hemorrhagic Fever (DHF). It is considered as one of the acute febrile diseases caused by one of the four closely related virus serotype of the genus flavivirus. It can be transmitted by Aedes Aegypti mosquito to humans usually attacking during the day. One will experience onset of fever, severe headaches, muscle and joint pains which will give name to Breakbone Fever or Bonecrusher. There are also rashes characterized by bright red petechaie commonly seen on the lowers limbs and on the chest. There may also be gastritis associated to abdominal pain, nausea, vomiting, or diarrhea. Proper attention of health care
provider should be given including good assessment, early detection or diagnosis and medications which are essential for total interference of prevention.
GOAL
General Goal:
• To be knowledgeable about the nature of Dengue Fever Syndrome, management and treatment to be able to render effective nursing care to the client.
Specific Goal:
• To be familiar with the etiology of the disease
• To know the pathophysiology of the disease
• To be aware of the signs and symptoms
• To know its complications
• To be knowledgeable on how to prevent the disease
• To know the treatment and how to apply it • To know the diagnostic exam
PATIENT’S PROFILE
Name: CJS Age: 13 years old Gender: Male
Address: # 32 Natividad St. Malanday San Mateo, Rizal Date of Birth: October 24, 1995
Place of Birth: Marikina Nationality: Filipino Religion: Roman Catholic Civil Status: Single
Occupation: N/A
Date of Admission: August 24, 2009 Time of admission: 9:00 pm
Physician: Dra. Del Valle
Place of Admission: H-Vill Hospital
a.1 CHIEF COMPLAIN
• The patient complains of abdominal pain, headache, fever and general flushing of skin with on and off vomiting.
a.2 PRESENT ILLNESS
• Four days prior to admission, the patient had an intermittent fever associated with abdominal pain, headache, and general flushing of the skin with on and off vomiting. A few hours prior to admission still the above sign and symptoms remain but already have (-) vomiting with accompanying chills and was diagnosed with Dengue fever Syndrome.
a.3 PAST MEDICAL YEARS
• It was according to the patient that he wasn't been hospitalized yet not until when he was diagnosed with Dengue Fever Syndrome. Before that diagnosis, he was already experiencing fever and his mom gives him a Paracetamol for remedy.
a.4 FAMILY HISTORY
• According to his grandmother the only disease that the family has genetically is Diabetes Mellitus and no other diseases noted.
a.5 SOCIAL HISTORY
• CJS is the son of Mr. and Mrs. SJ. CJS is currently on the secondary level of education at Roosevelt College at Malanday, Marikina City, near their place.
• His father works as a seaman while his mother is a housewife; his grandmother is also living with them. Hence, his grandmother and his mother were the ones responsible in all the household chores.
According to CJS, he eats vegetables and fish instead he prefers eating hotdogs. Furthermore he has no other vices except for computer games. After school hours, he goes directly to the computer shop together with his brother and friends.
a.6 ENVIRONMENTAL HISTORY
• According to the patient the environment that the family have has an open drainage, wherein big rats and cockroaches can be seen. The house is cleaned by his mother and grandmother. It was described by the patient that there are parts of their house that is deprived from light.
•
C. HISTORY OF ILLNESS
• During the mid of August, CJS, started experiencing fever that persist only at night. As a remedy his mom gave him Paracetamol to lower his body temperature. Except from fever he’s also experiencing abdominal pain, headache and general flushing of the skin with on and off vomiting.
As the above signs and symptoms persists, his parent decided to bring him to the hospital.
Upon the physical assessment and after several diagnostic procedures that the patient had undergone, he was diagnosed with Dengue Fever Syndrome (DFS) and was admitted under the service of Dra. Del Valle.
THEORETICAL FRAMEWORK
CJS, is at the stage of puberty, was diagnosed of having Dengue Fever Syndrome (DFS).At the clinical check-up, the physician was able to identify some clinical signs of it and was referred to Dra. Del Valle. The case of CJS can be correlated with the theory of Florence Nightingale
Application Theory:
The case of CJS can be correlated with the theory of Nightingale wherein, the environment of the patient is a factor leading to recovery. Having a clean, well ventilated and quite environment is important in. With a nurturing environment, the body could repair itself.
PHYSICAL EXAMINATION
PHYSICAL ASSESSMENT
1. Received Patient on bed awake conscious and coherent
2. With IVF D5LR 1000ml at 450 cc level and regulated at 25gtts/min.
I. LINEAR MEASUREMENT 1. Height: 5’4’’
PHYSICAL ASSESSMENT NAME: CJS
DATE OF ASSESSMENT: August 24, 2009 VITAL SIGNS:
BP: 10070 mmHg PR: 76bpm RR: 22bpm Temp: 36.5˚C
General Appearance: Received lying on bed, conscious and coherent. Pale and has general flushing with rashes Area assessed Technique
Used
Normal Findings Actual Findings Rationale
Area Assessed Method Used Normal Findings Actual Findings Rationale
SKIN Color and pigmentation Lesions Texture Moisture Temperature Mobility and turgor
NAILS
Nail bed color Shape Lesions Thickness capillary refill Inspection Inspection Palpation Palpation Palpation Palpation Inspection Inspection Inspection Palpation Palpation
Light to deep brown
No lesions, scars or inflammation Smooth
Moist
The skin springs back to its previous state after being pinched
Pink Convex
No inflammation of the skin around the nail Firm General flushing No lesions, but presence of scars Smooth Moist
The skin springs back
to its previous state after being pinched Pale
Convex
No inflammation of the
skin around the nail
Decrease WBC in the body Normal Normal Normal Normal Normal Decrease RBC in the body Normal Normal Normal
Firm
Normal capillary refill
Normal
(less than 3secs)
HEAD Size Symmetry HAIR Color Texture Other findings SCALP Distribution of hair Lesions Other findings FACE Skin color Texture Facial movement EYES Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection
Proportion to the body and the skull is
rounded and smooth Symmetrical
Black
Curly hair, straight No nits/lice present
Evenly distributed No inflammation, lumps or masses
Light to deep brown Smooth
Symmetric facial movement
Proportion to the body
and the skull is rounded and smooth Symmetrical No nits/lice present No inflammation, lumps or masses Pinkish Symmetric facial Symmetric facial movement Normal Normal Normal Normal Normal Normal Normal Normal Due to fever Normal Normal
External structure Eyebrows Eyelashes Eyelids EARS Color Symmetry Shape and size
NOSE Color Shape Discharges MOUTH Lips Symmetry Moisture TONGUE Position Color Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Evenly distributed Evenly distributed,
Evenly distributed, curved outward
Same as facial color Symmetrical at the level of the eyes corner
Symmetric to head No discharges and inflammation
Same as facial color
Same with facial color Symmetric No discharges Symmetric Pink Moist Positioned at the center can move freely Pink conjunctiva Evenly distributed Evenly distributed Symmetric to head No discharges and inflammation Normal
Same with facial color Symmetric No discharges Symmetric Pink Dry Central position Dull red Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal D/t poor nutrition Normal
Texture Mobility Lesions NECK Position Symmetry Range of movements
UPPER AND LOWER EXTREMITIES Size Symmetry Distribution of hair Skin color Lesions Temperature Inspection Inspection Inspection Inspection Inspection Inspection Palpation Inspection Inspection Inspection Inspection Inspection Inspection Dull red Smooth
Can move freely No lesions or inflammation Head centered Symmetrical Smooth movements without discomfort Symmetric and at midline position Equal size Symmetrical Evenly distributed Light to deep brown No lesions,
deformities or inflammation Normal
Smooth
Can move freely No lesions or inflammation Head centered Symmetrical Smooth movements without discomfort Symmetric and at midline position Equal size Symmetrical Evenly distributed Light to deep brown No lesions, deformities or inflammation Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Due to disease Normal
GORDON’S 11 FUNCTIONAL HEALTH PATTERN FUNCTION BEFORE HOSPITALIZATION DURING HOSPITALIZATION INTERPRETATION Nutrition • Eats 3x a day
• He loves to eat bread & processed foods such as hotdog, tocino, longanisa, and others. • He doesn’t eat vegetables and fish • Seldom drinks water • Mostly eat bread • This time he frequently drinks water
• The Doctor ordered DAT diet to the patient except dark colored food
• To replace fluid loss
Elimination • He is able to urinate & defecate normally everyday by himself • He doesn’t have any problem on his elimination • Defecates usually early in the morning before going to school • He can still urinate & defecate by himself even without an assistance
• His condition doesn’t affected his
elimination pattern
Sleeping • Has a regular sleeping pattern • Normal sleep is 6-8 hrs. per day but he naps for 1-2 hrs in the afternoon • Disturbed sleeping pattern • Due to adherence to time of medication & vital signs monitoring
Cognitive-Perceptual Pattern • Has a normal cognitive perception • He is responsive & can • Portraying cooperativeness
• Can comprehend well • He responds appropriately to verbal & physical stimuli communicate well Self-
Perception-Self concept • Perceived himself as a good friend, brother & son.
• This time he perceives himself as an approachable person
• Due to his ability to establish good rapport to other people
Role Relationship
Pattern • He was able to do his responsibilitie s as a son & brother
• This time his role as a patient is not fully met
• Due to his condition, he is not aware of performing his real role in this field. Sexuality-Reproductive Pattern • He doesn’t think of the things like having a girlfriend & getting married.
• Same • Due to his youthful
mind, it is still not his priority in life
Coping Stress &
Tolerance Pattern • He doesn’t fully identifies his stressors.
• Same • At his age, he still
has a playful mind & he doesn’t mind the stressors in life. Activity-Exercise
Pattern • His daily routine on playing computer. His daily activities were limited in waking up in the morning to attend his class & after that going to computer shop. • He interacts with his grandmother & other people around him • Cooperates well to the doctor & nurses. • He only focuses on simple things. Value-Belief
Pattern • He is a Catholic • Due to their culture preferences & parent’s influence
Health Perception – Health Management Pattern • He perceived his health in the state of good condition • He thinks that he is not healthy
HEMATOLOGY EXAMINATION REFERENCE VALUE EXAM RESULTS INTERPRETATION Aug. 24,2009 Aug. 26, 2009
RBC COUNT 4-6X1012/ L 5.1 4.7 Within normal range
WBC COUNT 5-10X10g/L 3.0 2.4
HEMOGLOBIN Male:
140-170gms/ L 155 138 Within normal range
Female: 120-140gms/L
HEMATOCRIT
Male:0.43-0.54
0.47 0.42 Within normal range
Female: 0.37-0.45 DIFFERENTIAL COUNT SEGMENTERS 0.55-0.65 0.57 0.40 LYMPHOCYTES 0.25-0.35 0.43 0.60 MONOCYTES 0.02-0.06 ---EOSINOPHIL 0.01-0.03 ---BASOPHIL 0.01-1.0 ---CLOTTING TIME --- ---BLEEDING TIME --- ---BLOOD TYPE --- ---ESR --- ---STAB --- ---PLATELETS 150-400x103 g/L
Brand name/ Generic name
Classification Action Indication Adverse Effect Contraindication Nursing consideration Acetaminophen
(Paracetamol) Nonopoiod analgesics and anti pyretics Produce analgesia by blocking pain impulses by inhibitinfg synthesis of prostaglandi n in the CNS or of other substances that sensitize pain receptors to stimulation. Symptomatic relief of pain and fever. Relief of headache, toothachge, back pain, dysmenorrheal, myalgias,neuralg ias, etc. Analgesics and anti pyretic for patients hypersensitive to aspirin Rash, nausea, vomiting, blood dyscrasias , anemia, analgesic nephropathy , nephrotoxicity , hypersensitivity reactions Hypersensitivity.
Patients Patients with alcoholic liver disease. Impaired liver or kidney function
Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation Subjective: “Nangangati ako” as verbalized by the patient Objective: V/S taken: Aug 24,2009 as of 4pm BP – 100/70mmHg Temp. – 36.5˚C RR – 22 bpm PR – 76bpm - Redness of the skin - Skin rashes
Risk for impaired skin integrity related to
Short Term Goal: Within 2hours of nursing intervention, patient will demonstrate behavior in preventing skin impairment. Long Term Goal: After period of hospitalization, the patient will be able to understand and apply treatment/ or therapy, regimen to the skin impairment.
Independent Nursing Action: -Monitor vital signs - Provide skin hygiene through sponge bathing & changing regularly - Keep bed clothes dry, use non-
irritating materials, & keep bed wrinkled free
- Palpate skin lesions for size, shape, consistency, texture & hydration - Encourage
reposition schedule for client
-Provide information to the client about the importance of regular observation & effective skin care
- Serves as baseline data to determine any discrepancies -To maintain skin integrity at optimal level.
-To avoid lesions, scratching of skin & harboring of
microorganism. - To assess extent of involvement of skin impairment. -To prevent friction that may cause irritation of the skin - To promote wellness by gaining knowledge on treatment/ therapy After 8 hours of rendering effective nursing intervention the goal was
completely met as evidenced by patient’s demonstration of behavior in preventing skin impairment. -patient verbalizes comfortability, decrease feeling of itchiness and gradual disappearance of rashes. -patient’s skin color(pigmentation) becomes normal (absence of redness)
Assessment Nursing Diagnosis Planning Nursing
Intervention
Rationale Evaluation
Subjective: “Masakit ang tiyan ko” as verbalized by the patient. Objective: V/S taken: Aug 24,2009 as of 4pm BP – 110/70mmHg
Acute pain related to clinical
manifestations of dengue hemorrhagic fever
Short Term Goal: Within 8 hours of effective nursing intervention patient will be able to feel less pain on his abdomen.
Long Term Goal:
Independent Nursing Action: -Perform a comprehensive assessment of pain - Provide nonpharmacologic management like change of position & applying warm
- To improve quality, frequency & location of pain.
-To alleviate pain.
After 8 hours of rendering effective nursing intervention the goal was
partially met as evidenced by less guarding of stomach and patient’s verbalize partial relieve of pain.
PATHOPHYSIOLOGY
↓
Bite of a aedes aegypti mosquito carrying a virus ↓
Virus goes into the circulation
Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation Subjective: “Mainit po ang katawan ko”as verbalized by the patient. Objective: V/S taken: Aug 25,2009 as of 6pm BP – 110/70mmHg Temp. – 38.6˚C RR – 30bpm PR – 67bpm - Flushing of skin - Skin warm to touch Elevated body temperature related to
Short Term Goal: Within 8 hours of effective nursing intervention patient body temperature will be decrease from 38.6- 37.5˚C Long Term Goal: After period of hospitalization, the patient will be able to know the proper management of hyperthermia
Independent Nursing Action: -Monitor vital sign - Monitor intake and output - Perform TSB
-Increase oral fluid intake
- Provide safe & quite environment -Inform the patient about proper management of fever Dependent nursing intervention: - Administer medications as order by physicians such as Paracetamol or any anti –pyretic drugs.
- Serves at baseline data. -To know the fluid balance of the body - To reduce body temperature through the process of conduction - To prevent dehydration and support circulating volume. - To provide conducive place to rest .Inform the patient about proper management of fever - To be able for the patient to know the proper management. -To elevate the patient’s body temperature. After 8 hours of rendering effective nursing intervention the goal was completely met as evidenced by patient’s body temperature decreases from 38.6-37.5˚C. Patient’s skin not warm to touch. Normal complexion of the skin. Non- predisposing Factor: - Age:13 y/o - Male Predisposing Factor: -Immuno compromised - Environment
↓
Infects cells & generate cellular response ↓
Initiates destruction of the platelet ↓
↑ Potential for hemorrhage ↓
Stimulates intense inflammatory response ▼ ▼
Release of exogenous pyrogens The body releases
↓ inflammatory mediators ↑ WBC (Neutrophils & Macrophages) (Histatin, Kinins) ↓ ↓
Release of endogenous pyrogens Vascular response
↓ ↓
Reset of hypothalamic thermostat Redness & Heat ↓ ↓
Fever Headache, Vomiting ▼ ▼ Epistaxis, Abdominal pain Muscle contract Blood vessels Circulatory Collapse Shock
To produce construct to ↓ Additional heat prevent loss of body heat DEATH ↓ ↓
SHIVERING CHILLS
Discharge Planning A. Patient's Name:
> C.J.S a thirteen year-old male patient, who was diagnosed with Dengue Hemorrhagic Fever.
B. Diet:
> Encourage nutritious foods like vegetables, meat and fruits. C. Medications:
> Give acetaminophen in case the temperatures increases. > Give oresol to replace fluid in the body.
D. Treatment:
> Increased oral fluid intake. E. Health Teaching:
> D- discuss the possible source of infection of the disease. > E- educate the family/patient on how to eliminate those vectors. > N- Never stocked water in a container without cover.
> G- Gallon, container and tires must have proper way of disposal. > U- Use insecticides at home to kill or reduce mosquito.
> E- Encourage the family of the patient to clean the surroundings to destroy the breeding places of mosquito.
