A Case Study in Delos Santos Hospital

An NCM 501 204 Requirement DLSDLS-STI College, Quezon City

Presented By Group 29 B
Abala Annale Cabauatan, Ryan Charles Javelosa, Sebastian Jose Ladringan, Eduard Manalo, Miguel Sanchez, Glenn Soliven, Liezl

Case Study
A. Nursing History
1. 2. 3. 4. 5. 6. 7. 8. Personal Data Chief Complaint Diagnosis History of Present Illness Past Health History Family Health History Personal and Social History Usual Pattern of Daily Living

B. Competencies C. Clinical Appraisal

Case Study
D. Anatomy and Physiology E. Pathophysiology F. Theoretical Framework G. Laboratory Exams H. Nursing Care Plan I. Drug Study J. Discharge Planning

A. Nursing History

A. Nursing History
1. Personal Data Patient Name: G.S Address: Quezon City Age: 22 years old Date of Birth: november 27, 1987 Place of Birth: manila Gender: Male Nationality: Nationality: Filipino Religion: Roman Catholic

A. Nursing History
1. Personal Data Registration Date: September 21, 2010 Admission Date: September 21, 2010 Registration Time: 5:30 PM Admission Time: 6:45 PM

A. Nursing History
2. Chief Complaint: Fever, Abdominal pain

3. Diagnosis: Dengue Hemorrhagic Fever

A. Nursing History
4. History of Present Illness: Admitted for the first time due to fever 5 days PTA, patient had fever, documented 39 C, not accompanied with vomiting, abdominal pain, diarrhea, cough and colds, fair appetite. Patient was given paracetamol 500mg/tab, every 4 hours that altered temporary relief.

A. Nursing History
4. History of Present Illness: 3 days PTA, still with fever accompanied with vomiting of 6 episodes more salivary secretions. Patients was given Plasil 10mg/tab for every vomit. Patient was noticed to have poor appetite, but not accompanied with bleeding.

A. Nursing History
4. History of Present Illness: 1hour PTA, due to persistent fever and increased severity of abdominal pain, mother sought consult to another private physician, CBC with APC was requested revealing low platelet count (80) and Hemo concentration. He was then advised for admission.

A. Nursing History
5. Past Health History: (-) Hospitalization (+) Chicken Pox (-) Measles (+) Mumps (-) Allergies to food and drugs 6. Family Health History: (+) HPN (paternal) (-) DM (-) PTB

A. Nursing History
7. Personal and Social History: 2/2 siblings, delivered via NSD at home assisted by a midwife. Breastfed for 1 year Patient lives with his aunt, cousins and nephews An average first year HS student Prefers to eat vegetables Stay at home most of the time and plays computer

A. Nursing History
7. Personal and Social History: Outdoor activities are basketball and running No intake of prohibited drugs No relationship to opposite sex Sometimes wearing helmet and seatbelt when traveling No suicidal attempts

A. Nursing History
8. Usual Pattern of Daily Living: Living:
Activities Before Hospitalization
Day 1 Rest and sleep pattern Irritable, restless due of increase abdominal pain and persistent fever accompanied w/vomiting Irritable, restless

During Hospitalization
Day 2 With a good sleep, restless at times but not irritable at all. With appetite normal urine elimination normal stool elimination Day 3 With good sleep, the patient is more relax and more comfortable With appetite normal urine elimination normal stool elimination

Nutrition Elimination Urine Stool

Poor appetite normal urine elimination normal stool elimination

a. b.

Poor appetite normal urine elimination normal stool elimination

a. b.

a. b.

Hygiene

With proper hygiene

With proper hygiene

With proper hygiene

With proper hygiene

B. Competencies

B. Competencies
Criteria
Physical or Motor Competencies

Actual Observation
The patient is weak Flushes on the skin With body malaise Can communicate verbally a. Patient cannot accept that he has dengue b. Minimal interaction with family members c. With rosary in his hand

Mental Competencies a. Emotional b. Social c. Spiritual

C. Clinical Appraisal

C. Clinical Appraisal
General /Physical Appearance a. Skin

Normal

Present Condition

Warm to touch; elastic Pallor and mobile as to turgor; no lesions, edema or tenderness

b. Head

Rounded scalp; has no lesions or tenderness; smooth skull contour; absence of nodules or masses

Rounded, normocephalic and symmetrical, with frontal, parietal and occipital prominence

C. Clinical Appraisal
General /Physical Appearance c. Eyes

Normal
Eyebrows symmetrically aligned; lashes equally distributed; eyelids are intact without discoloration; lids close symmetrically; clear bulbar conjunctiva; shiny smooth and pink palpebral conjunctiva; pupils equal and round

Present Condition
Eyebrows are symmetrically aligned; no discharge; no discoloration; lids close symmetrically; bilateral blinking

C. Clinical Appraisal
General /Physical Appearance d. Nose

Normal

Present Condition

External nose not Pink mucosa; no tender upon light lesions palpation; air moves freely as client breaths thru the nares; pink mucosa; no lesions; no discharges Lips are moistened and reddish in color; pink gums; Pallor; dry lips; pink gums

e. Mouth

C. Clinical Appraisal
General /Physical Appearance f. Neck

Normal

Present Condition

Head centered; Muscles equal in size; symmetrical; full range head centered of motion; lymph nodes not palpable or enlarged Symmetrical chest wall; quiet; rhythmic and effortless respiration Symmetric chest; spinal column is vertically aligned and straight; symmetric pulse volume

g. Heart; Lungs

C. Clinical Appraisal
General /Physical Appearance h. Abdomen

Normal
Flat; rigid; unblemished skin; symmetric movement caused by respiration

Present Condition
Limited movement due to pain or diseased process

D. Anatomy and Physiology

The Cardiovascular System

Cardiovascular System
Purpose Responsible for transporting materials throughout the entire body Transports nutrients, water, and oxygen to body cells Carries away wastes such as carbon dioxide that body cells produce Travels through your entire body connecting all your body cells

Cardiovascular System
Three Major Parts 1. The Heart 2. The Blood (Blood Cells) 3. The Blood Vessels

Cardiovascular System
1. Heart It's job is to pump blood and keep the blood moving throughout your body.

Cardiovascular System
2. Blood The average adult has between 5 to 6 liters of blood The blood travels through thousands of miles of blood vessels right within the body

Cardiovascular System
2. Blood It carries nutrients, water, oxygen and waste products to and from your body cells

Cardiovascular System
2. Blood Most of the blood is made up of a watery, proteinproteinladen fluid called plasma. plasma.

Cardiovascular System
2. Blood A little less than half of this blood volume is composed of red and white blood cells, cells, and other solid elements called platelets.

Cardiovascular System
2. Blood A little less than half of this blood volume is composed of red and white blood cells, and other solid elements called platelets. platelets.

Cardiovascular System
2. Blood Cells Red Blood Cells are responsible for carrying oxygen and carbon dioxide. RBC pick up oxygen in the lungs and transport it to all the body cells.

Cardiovascular System
2.

Blood Cells After delivering the oxygen to the cells, RBC gathers up the CO2 and transports it back to the lungs where it is removed from the body when we exhale.

Cardiovascular System
2. Blood Cells White Blood Cells help the body fight off germs. WBC attack and destroy germs when they enter the body.

Cardiovascular System
2. Blood Cells Sometimes our WBC need a little help and the doctor will prescribe a drug to help our WBC fight a large scale infection.

Cardiovascular System
2. Blood Cells Platelets are blood cells that are responsible for clotting. They start to stick to the opening of the damaged blood vessels.

Cardiovascular System
2. Blood Cells As the platelets stick to the opening of the damaged vessel they attract more platelets, fibers and other blood cells to help form a plug to seal the broken blood vessel.

Cardiovascular System
2. Blood Cells When the platelet plug is completely formed the wound stops bleeding.

Cardiovascular System
3. Blood Vessels Types: a. Arteries b. Veins c. Capillaries

Cardiovascular System
3. Blood Vessels
Arteries are blood vessels that carry oxygen rich blood away from the heart.

Cardiovascular System
3. Blood Vessels Veins carry blood back toward your heart.

Cardiovascular System
3. Blood Vessels Capillaries are tiny blood vessels that connects arteries to veins. Nutrients, oxygen and waste in the blood, pass in and out thru here

E. Pathophysiology
Dengue Hemorrhagic Fever

E. Pathophysiology
What is Dengue Hemorrhagic Fever? Dengue hemorrhagic fever is a severe, potentially deadly infection spread by certain mosquitoes (Aedes aegypti ). (Aedes

E. Pathophysiology
What is Dengue Hemorrhagic Fever? It is a disease caused by any one of four closely related viruses (DEN1, DEN2, DEN3, DEN4)

E. Pathophysiology

How does DHF Spread? Dengue is transmitted to people by the bite of an Aedes mosquito that is infected with a dengue virus. The mosquito becomes infected with dengue virus when it bites a person who has DHS and after about a week can transmit the virus while biting a healthy person. Dengue cannot be spread directly from person to person.

E. Pathophysiology
What are the symptoms of the disease? Principal symptoms are high fever that lasts from 2 to 7 days Severe headache, backache, joint pains, abdominal pain, nausea and vomiting, eye pain and rash This stage is followed by hemorrhagic manifestations , tendency to bruise easily or other types of skin hemorrhages, bleeding nose or gums, and possibly internal bleeding

E. Pathophysiology
How does the virus affect the cardiovascular system? The capillaries become excessively permeable or leaky, allowing the fluid component of the blood to escape from the blood vessels. This leads to failure of the circulatory system and shock, followed by death, if circulatory failure is not corrected.

E. Pathophysiology
What is the treatment for DHF? There is no specific medication for DHF. It can however be effectively treated by fluid replacement therapy and rest if an early clinical diagnosis is made. Hospitalization is frequently required in order to adequately manage DHF.

F. Theoretical Framework

F. Theoretical Framework Imogene Kings Conceptual Framework And Model of Transaction

F. Theoretical Framework
Imogene Kings theory of goal attainment begins with her conceptual framework (fig 1). She states that there is a relationship between personal, interpersonal and social systems. Within this connection, she identified 10 nursing concepts that are essential within this working link.

F. Theoretical Framework
These are self, role, perception, communication, interaction, transaction, growth and development, stress, time and personal space. These concepts are to be used by nurses in concrete nursing situations.

F. Theoretical Framework
From the conceptual framework, a transaction model was designed (fig 2). This process describes the nature of and standard for nursenursepatient interactions that leads to goal attainment
Feedback Perception Judgment Nurse Client Action Reception Action Judgment Perception Feedback Interaction Transaction

F. Theoretical Framework
In relation to this case study, Kings model of transaction illustrates an open channel communication between the nurse the patient, and other individuals involved such as family members.

F. Theoretical Framework
Nightingale Theoretical Framework
Nightingales philosophy primarily focuses on the environment and the patients response to their environment, to allow nature to act on the patient.
Nursing Environment

Health

Person

F. Theoretical Framework
Nightingale Theoretical Framework
Environment, person, health, and nursing are the foundation of Nightingales theoretical framework.
Nursing Environment

Health

Person

F. Theoretical Framework
Environment can be defined as anything that can be manipulated to place a patient in the best possible condition for nature to actto act promote health and healing.
Nursing Environment

Health

Person

F. Theoretical Framework
Physical components include areas such as ventilation, warmth, light, nutrition, medicine, temperature, stimulation, and activity.
Nursing Environment

Health

Person

F. Theoretical Framework
Person The one who is receiving careNightingale believed care in a holistic view of a dynamic and complex being, comprised of the following components: Spiritualy SpiritualySocial yEmotional yIntellectual yPhysical y

F. Theoretical Framework
Health Nightingale viewed health as natural, a reparative process and disease as the interruption of natures process (explained as the lack of some need, such as ventilation, cleanliness, efficient drainage ). Nightingale also believed in health prevention and promotion.

F. Theoretical Framework
Nursing Nightingale worked diligently to define nursing and delineate the boundaries of nursing care. As the first nursing theorist, her pioneering efforts in this area set the standard for others who followed. Nightingales beliefs were historically significant for nursing, she believed that: 1. nursing was a spiritual calling requiring ethics and a societal commitment to help those suffering, 2. nurses should be formally educated to provide quality care

F. Theoretical Framework
Nursing Nightingale viewed nursing as the science of environmental management ( with nurses altering the patients environment to promote health and healing).

G. Laboratory Exams

G. Laboratory Exam
Results give emphasis on the decrease of platelet and WBC Increase in Lymphocytes which indicates a viral infection The seen plummeting of the platelet indicates the pathology of a hemorrhage Increase in lymphocytes results in a fever Symptoms plus the result of the of the hematology test leads to a conclusion that the client is suffering from Dengue.

H. Nursing Care Plan

H. Nursing Care Plan 1 (Assessment)

Subjective:
"masakit po yung tiyan ko as verbalized by the patient

Objective:
Vital Signs BP 80/50 T 37.5 PRR >febrile >body malaise >grimace >dry lips

H. Nursing Care Plan 1 (Diagnosis)

Abdominal pain related to excessive loss of body fluids as evidence by vomiting, dry lips and body malaise

H. Nursing Care Plan 1 (Planning)

1. Patient will not complain for abdominal pain 2. Loss body fluids will be replaced 3. Reduce/stop vomiting 4. Reduce the risk for Dehydration 5. Patient will be comfortable and resting

H. Nursing Care Plan 1 (Intervention)

Independent: 1. Assess patients condition 2. Monitor vital signs 3. Monitor patients intake and output of fluid 4. Encourage patient to increase fluid intake 5. Maintain bed rest Dependent: 1. Carry out doctors order 2. Give medication if necessary and as ordered by the doctor

H. Nursing Care Plan 1 (Rationale)

Will serve as baseline data Indicator for any abnormal manifestation Reduce the risk of Dehydration To replace loss body fluids To provide comfort and full recovery

H. Nursing Care Plan 1 (Evaluation))

After Nursing Interventions: 1. Reduce the risk for dehydration Met. The intake of fluid was equal to the output monitored Met. Appearance was back to normal 2. Vomiting was reduced Met. Theres an increase in appetite 3. Body malaise was gone and there was increase in energy level as evidence by increase food intake and (+)ambulation

H. Nursing Care Plan 2 (Assessment)

Subjective:
"nilalamig po ako tsaka nanghihina as verbalize by the patient.

Objective:
Vital Signs BP 80/50 T 37.5 PRR >febrile >body malaise >accompanied by chills >dry lips

H. Nursing Care Plan 2 (Diagnosis)

Increase in body temperature related to Alteration in thermoregulation as evidence by chills, warm to touch, body malaise and flushes on the skin

H. Nursing Care Plan 2 (Planning)

1. 2. 3. 4. 5. Body temperature will be normalize Skin color and integrity will normalize Chilling will stop Patient will be comfortable and resting Should be refer accordingly to PEDIATRICIAN for medication purposes PRN (if necessary)

H. Nursing Care Plan 2 (Intervention)

Independent: 1. Assess patients condition 2. Render Tepid Sponge Bath and recheck every 1515-30 minutes 3. Encourage patient to increase fluid intake 4. Monitor vital signs 5. Maintain bed rest Dependent: 1. Carry out doctors order 2. Give medication if necessary and as ordered by the doctor

H. Nursing Care Plan 2 (Rationale)

Will serve as baseline data To decrease body temperature Aids in normalizing body temperature and reduce the risk of dehydration Indicator for any abnormal manifestation To provide comfort and full recovery

H. Nursing Care Plan 2 (Evaluation)

After Nursing Interventions: 1. Body temperature was normalized 2. Skin is normal in color and integrity 3. Body malaise and chills were gone and there was increase in energy level as evidence by (+)ambulation 4. Reducing the risk of Dehydration was met

I. Drug Study

I. Drug Study
DRUG ACTION CONTRAINDICATIONS SIDE EFFECTS

Famotidine 20mg

Competitively blocks histamine H2H2receptors thus reducing basal, nocturnal and stimulated gastric acid secretion. Pepsin secretion is reduced resulting in decreased peptic activity. It effectively heals duodenal and gastric ulcers and prevents recurrence.

Cirrhosis of the liver, impaired renal or hepatic function, lactation.

Headache, dizziness, fatigue, constipation, diarrhea, abdominal discomfort, nausea, rash, gynaecomastia, impotence.

J. Discharge Planning

J. Discharge Planning
M - Medications Remind the client to follow the right dose and time of medication to stabilize the condition of the client. E - Exercise No strenuous exercise until the client feels capable and with consultation from the doctor. T - Treatment Explain to the client the importance of adequate physical as well as mental rest to regain normal strength.

J. Discharge Planning
H - Health Teaching ( Home Care) Provide the patient as well as the family information regarding things to watch out for at home once discharged from the hospital to avoid relapse of infection.  Encourage regular fluid intake to prevent dehydration.  Recommended restriction of caffeine, alcohol, as indicated to prevent untoward diuretic effect & possible dehydration.  Aspirin and non-steroidal anti-inflammatory drugs nonantishould be avoided as for those drugs may induce bleeding tendency.

J. Discharge Planning
H - Health Teaching ( Home Care)


Advice client as well as the family to apply insect repellent, wear clothes that covers arms and legs, close unscreened doors and windows, & clean places in the house that mosquitoes might live in.

J. Discharge Planning
O - Outpatient Remind the client to take note of the date scheduled for checkcheck-up with the doctor after discharge. D - Diet Remind the patient to choose foods that are rich in protein, vitamins, minerals and carbohydrates, and to be mindful of food sources, to re-establish clients health. re-