DENGUE

SUBMITTED BY: BSN 3 GROUP 2 JANE MICHELLE CESARIO

SUBMITTED TO: Mrs.MARIBEL MURILLO

A. GENERAL DATA 1. PATIENT NAME: IE.DR 2. ADDRESS: Laoac, Pangasinan 3. AGE: 4 years old 4. SEX:Male 5. BIRTH DATE: April 20, 2009 6. RANK IN THE FAMILY: 2 child 7. NATIONALITY: Filipino 8: CIVIL STATUS: Single 9 .DATE OF ADMISSION: July 22,2013 10. ORDER OF ADMISSION: Admit to pedia ward Secure consent TPR q4 every shift Diagnostics: CBC, platelet, urinalysis 11. ATTENDING PHYSICIAN: Dr. Viduya 12. ADMITTING DIAGNOSIS: Fever for 3days
nd

B.CHIEF COMPLAINT Intermitent fever for 3days C.HISTORY OF PRESENT ILLNESS

a day prior to admission the patient experienced hyperthermia. D.PAST HEALTH HISTORY/STATUS He didnt have any operations, surgeries or any allergies to food or drugs . He had measles, mumps and common colds. He has been immunized and completed vaccinations for Bacillus Calmette Guerin (BCG), Oral Polio Virus (OPV), Diphtheria, Pertusis, andTetanus (DPT), Hepatitis B and MMR. E.FAMILY ASSESSMENT

NAME

RELATION

AGE

SEX

OCCUPATION

EDUCATIONAL ATTAINMENT College graduate

J.DR J.DR

Mother Sister

32 7

Female Female

OFW Student

F.SYSTEM TO REVIEW-Gordons 11 Functional Health Patterns Assessment 1.HEALTH PERCEPTION-HEALTH MAINTENANCE PATTERN -Health is only physical it is a wholeness of a personas verbalized by the patient. 2.NUTRITIONAL-METABOLIC PATTERN BEFORE HOSPITALIZATION:The patient eats 3 times a day and with afternoon snacks. According to the SO of the patient, he eats meat, fish and also vegetables. He doesnt have any allergies on foods and drugs. His appetite is moderate and usually depends on the food being served. He didnt complain any difficulty in swallowing. DURING HOSPITALIZATION:The patient has loss his appetite and hasnt eaten a lot. He is on a DAT (Diet asTolerated) EDCF (Except Dark Colored Foods). 3.ELIMINATION PATTERN BEFORE HOSPITALIZATION:The patient does not have any problem on her elimination pattern. He usuallyurinates 4-5 timesa day without any difficulty. He added that the color of her urine is light yellow. He didnt feel any pain in urination. The patient defecates once a day usuallyearly in the morning with yellow to brown color. He verbalizedthat sometimes however, it is hard in consistency with dark color, which generallydepends on what he eats. DURING HOSPITALIZATION: The patient urinates 2-3 times a day. The color of his urine is yellow. The patientdefecates once every two days.

4.ACTIVITY EXERCISE PATTERN BEFORE HOSPITALIZATION:He could perform activities of her daily living. DURING HOSPITALIZATION: His activity was limited lying on bed but the patient is given her bathroom privileges. 5.SLEEP-REST PATTERN BEFORE HOSPITALIZATION:He has the normal 6-8 hours of sleep. He also has his nap time for 1-2 hours a day.Sleeping and watching the television are his form of rest. DURING HOSPITALIZATION:He doesnt have the adequate time of sleep since he is disturbed with the nursesthat enter the room every now and then, and because of the environmental changes of his surroundings. He also has inadequate time to rest since she doesnt have enough time to sleep.

6.COGNITIVE-PERCEPTUAL PATTERN He sees herself as a person with a good personality. She has been a good brother and daughter. He said he has to be a good person in order not to hurt others. 7.ROLE-RELATIONSHIP PATTERN BEFORE HOSPITALIZATION:He has a close relationship with her family. They were two siblings in their family. He was the youngest. I was also able to ask his mother about his being a son andshe confessed that he is a good son but at times he doesnt obey her. DURING HOSPITALIZATION:He had more time to bond with her family. 8.SEXUALITY-REPRODUCTIVE PATTERN -none9.COPING STRESS TOLERANCE He does not fully identify her situations having stress but she always tell her parents when something is wrong. 10.VALUE-BELIEF PATTERN

He is a Roman Catholic devotee. She always goes with her family every Sunday to go tomass. He was taught by his family to believe and have fear to GOD. They usually believe inquack doctors. G. HEREDO-FAMILIAL ILLNESS PATERNAL (Deceased)

Maternal

Asthma None

IE.DR (patient) dengue

H. DEVELOPMENT HISTORY (according to Erickson, Freud, Piaget, Kohlberg, Fowler)

THEORIST Erickson

AGE Fidelity: Identity vs. Role Confusion (Adolescence, 13-19 years)

SEX FEMALE

PATIENT DESCRIPTION Existential Question: Who Am I and What Can I Be? The adolescent is newly concerned with how they appear to others. Superego identity is the accrued confidence that the outer sameness and continuity prepared in the future are matched by the sameness and continuity of one's meaning for oneself, as evidenced in the promise of a career. The ability to settle on a school or occupational identity is pleasant. In later stages of Adolescence, the child develops a sense of sexual identity. As they make the transition from childhood to adulthood, adolescents ponder the roles they will play in the adult world. Initially, they are apt to experience some role confusionmixed ideas and feelings about the specific ways in which they will fit into societyand may experiment with a variety of behaviors and activities (e.g. tinkering with cars, baby-sitting for neighbors, affiliating with certain political or religious groups). Eventually, Erikson proposed, most adolescents achieve a sense of identity regarding who they are and where their lives are headed. Cognition reaches its final form. By this stage, the person no longer requires concrete objects to make rational judgments. He or she is capable of deductive and hypothetical reasoning. His or her ability for abstract thinking is very similar to an adult. The genital stage affords the person the ability to confront and resolve his or her remaining psychosexual childhood conflicts. The ego is established in the latter. The person s concern shifts from primary-drive gratification (instinct) to applying secondary process-thinking to gratify desire symbolically and intellectually by means of friendships, a love relationship, family and adult responsibilities

Piagets theory of cognitive development FREUD

Formal operations (beginning at ages 1115) Genital stage 12 20 y/o

FEMALE

FEMALE

I.PHYSICAL ASSESSMENT A. GENERAL SURVEY Body proportions are normal. Posture is erect but slightly not comfortable when standing straight. Gait is rhythmic and coordinated with arms swinging at side when walking. Wears ordinary clothes such as shirt and shorts. He weighs 14.5 kilograms. There is slight body odor and breath odor. Interacts and communicates in an appropriate manner with others. He is alert and oriented with time, place and person. His speech is clear and can comprehend with instructions when asked. B. VITAL SIGN BP: 70/80mmHg PR: 93 beats per minute RR: 26 breaths per minute TEMP: 38 degree Celsius

C. REGIONAL EXAM 1. Hair, head and face:Head is normal cephalic, no lesions, and no complaints of pain when palpated. Can puff out cheeks, and can feel sharp and dull objects. 2. Eyes are symmetric to each other, eye bags noted due to lack of sleep, no swelling, lesions, and no complaints of eye pain; eyelashes are evenly distributed, curled outward; skin intact, no discoloration, symmetric eyelids and eyeballs; able to blink involuntarily; bulbar conjunctiva transparent, no lesions; palpebral conjunctiva, smooth, pink, no edema. 3. Nose: shape and size are symmetric; no lesions; as the client breaths normally; mucosa is pink and no lesions, intact nasal septum between the nasal chambers. 4. Ears: the color is light which is symmetric to her facial skin; firm, not tender and pinna recoils after it was folded; cerumen is sticky wet, no skin lesions, pus and blood. 5. Mouth and Throat: There are no lesions and or swelling noted on the mouth. Presence of tartar and cavities are seen on the front teeth. The tongue is reddish and in normal size. No inflammation of the throat. 6. Neck and Lymph Nodes: No pain when palpated. No swelling or inflammation. 7. Skin: fair complexion, no edema, no birthmark, no lesions, moisture in skin folds and axillae. 8. Nails: pinkish, intact epidermis improper grooming, no markings and capillary refill 1-3 second.

9. Thorax and Lungs: No signs of distressed when breathing, not using accessory muscle, and no pain when palpated. It is also symmetrical to each other. 10. Cardiovascular:No distension of Jugular veins. The pulse rate is palpated with 93 beats per minute rate and regular pattern. 11. Breast and Axilla: Breast are symmetrical to each other, there is no visible vein and no retraction and dimpling. No presence of mass and nodules with foul odor and no lesions. No enlarge lymph nodes. 12. Abdomen: Characterized as rounded, no lesions. No bruit sound. 13. Extremities: Both arms and legs are same with the skin tone of the body. Skin is warm to touch. No lesions and excoriations noted. 14. Genitals: not performed. 15. Rectum and Anus: not performed II. PERSONAL / SOCIAL HISTORY a. Habits/ Vices: watching television, playing. a. Caffeine: not drinking coffee b. Smoking: not smoking c. Alcohol: not drinking alcohol d. Tea: not drinking tea. E. drugs none b. Lifestyle When staying in house he watches television or playing with toys. c. Social Affiliation He doesnt participate in any affiliations. d. Rank in the family He is youngest among two siblings e. Travel (within 6 months) He didnt travel. f. Educational Attainment Still not going to school I. Environment History (Living/ Neighborhood/Circumstances)

Their house is bungalow and made of cement, they have their own comfort room and faucet as their source of water. They sell different kinds of candies as their source of living. They have their own tricycle as their transportation and they also use it as their service in their rolling store.

V.INTRODUCTION

Dengue Fever is caused by one of the four closely related, but antigenically distinct, virusserotypes Dengue type 1, Dengue type 2, Dengue type 3, and Dengue type 4 of the genus Flavivirus and Chikungunya virus. Infection with one of these serotype provides immunity toonly that serotype of life, to a person living in a Dengue-endemic area can have more than oneDengue infection during their lifetime. Dengue fever through the four different Dengue serotypesare maintained in the cycle which involves humans and Aedes aegypti or Aedes albopictusmosquito through the transmission of the viruses to humans by the bite of an infected mosquito.The mosquito becomes infected with the Dengue virus when it bites a person who has Dengueand after a week it can transmit the virus while biting a healthy person. Dengue cannot betransmitted or directly spread from person to person. Aedes aegypti is the most common aedesspecie which is a domestic, day-biting mosquito that prefers to feed on humans. INTUBATION PERIOD: Uncertain. Probably 6 days to 10 days st PERIOD OF COMMUNICABILITY: Unknown. Presumed to be on the 1 week of illness when virus is still present in the blood CLINICAL MANIFESTATIONS: First 4 days: >febrile or invasive stage --- starts abruptly as high fever, abdominal pain and headache; later flushing which may be accompanied by vomiting, conjunctival infection and epistaxis th 4 to 7th day: >toxic or hemorrhagic stage --- lowering of temperature, severe abdominal pain, vomiting and frequent bleeding from GIT in the form of melena; unstable BP, narrow pulse pressure and shock; death may occur; vasomotor collapse th th 7 to 10 day: >convalescent or recovery stage --- generalized flushing with intervening areas of blanching appetite regained and blood pressure already stable

MODE OF TRANSMISSION: Dengue viruses are transmitted to humans through the infective bites of female Aedesmosquito. Mosquitoes generally acquire virus while feeding on the blood of an infected person. After virus incubation of 8-10 days, an infected mosquito is capable, during probing and blood feeding of transmitting the virus to susceptible individuals for the rest of its life. Infected female mosquitoes may also transmit the virus to their offspring by transovarial (via the eggs)transmission. Humans are the main amplifying host of the virus. The virus circulates in the blood of infected humans for two to seven days, at approximately the same time as they have fever. Aedesmosquito may have acquired the virus when they fed on an individual during this period. Dengue cannot be transmitted through person to person mode.

CLASSIFICATION: 1. Severe, frank type >flushing, sudden high fever, severe hemorrhage, followed by sudden drop of temperature, shock and terminating in recovery or death 2. Moderate >with high fever but less hemorrhage, no shock present 3. Mild >with slight fever, with or without petichial hemorrhage but epidemiologically related to typical cases usually discovered in the course of invest or typical cases

GRADING THE SEVERITY OF DENGUE FEVER: Grade 1: >fever >non-specific constitutional symptoms such as anorexia, vomiting and abdominal pain >absence of spontaneous bleeding>positive tourniquet test Grade 2: >signs and symptoms of Grade 1: plus >presence of spontaneous bleeding: mucocutaneous, gastrointestinal Grade 3: >signs and symptoms of Grade 2 with more severe bleeding: plus>evidence of circulatory failure: cold, clammy skin, irritability, weak tocompressible pulses, narrowing of pulse pressure to 20 mmhg or less, coldextremities, mental confusion Grade 4: >signs and symptoms of Grade 3, declared shock, massive bleeding, pulse lessand arterial blood Pressure = 1 mmhg (Dengue Syndrome/DS) SUSCEPTABILITY, RESISTANCE, AND OCCURRENCE: >all persons are susceptible >both sexes are equally affected>age groups predominantly affected are the pre-school age and school age>adults and infants are not exempted >peak age affected: 5-9 years old DF is sporadic throughout the year. Epidemic usually occurs during rainy seasons (June November). Peak months are September October. It occurs wherever vector mosquito exists. DIAGNOSTIC TEST: Tourniquet tes

>Inflate the blood pressure cuff on the upper arm to a point midway between thesystolic and diastolic pressure for 5 minutes. >Release cuff and make an imaginary 2.5 cm square or 1 inch square just belowthe cuff, at the antecubital fossa. >Count the number of petechiae inside the box. A test is positive when 20 or more petechiae per suare are observed. Dengue haemorrhagic fever (DHF), a potentially lethal complication, was firstrecognized in the 1950s during the dengue epidemics in the Philippines and Thailand, but todayDHF affects most Asian countries and has become a leading cause of hospitalization and deathamong children in several of them. VI. ANATOMY AND PHYSIOLOGY The Immune System A second line of defense is housedwithin the body: a finely tuned immunesystem that recognizes and destroysforeign substances and organisms thatenter the body. The immune system candistinguish between the body's owntissues and outside substances c alledantigens. This allows cells of theimmune army to identify and destro yonly those enemy antigens. The abilityto identify an antigen also permits theimmune system to "remember" antigensthe body has been exposed to in thepast; so that the body can mount abetter and faster immune response thenext time any of these antigens appear.The immune system also includes other proteins and chemicals that assistantibodies and T cells in their wor k.Among them are chemicals that alertphagocytes to the site of the infection.The complement system, a group of proteins that normally float freely in the blood, move toward infections, where theycombine to help destroy microorganisms and foreign particles. They do this bychanging the surface of bacteria or other microorganisms, causing them to die.

VII. PATHOPHYSIOLOGY Medical Diagnosis T/C Dengue Hemorrhagic Fever/ Pleural Effusion, T/C Liver Pathology Definition Dengue Hemorrhagic Fever is a severe, potentially deadly infection spread by certain species of mosquitoes (Aedesaegypti). Pleural Effusion is excess fluid that accumulates in the pleural cavity, the fluid-filled space that surrounds the lungs.Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during inhalation. Liver Pathology a condition characterized by any liver diseases or condition

Predisposing Geographicacl area tropical islands in thePacific (Philippines) and Asia

Precipitating
Environmental conditions (open spaces with water pots, and plants)Immunocompromise Mosquito carrying dengue virus soldier sweaty skin

Aedesaegypti (dengue virus carrier) 812 days of viral replication on mosquitos salivary glands

Bite from mosquito (portal of entry in the skin)

Allowing dengue virus to be inoculated towards the circulation/blood (incubation days 3-14 days)

Redness and itchiness in the area

Virus disseminated rapidly into the blood and stimulates WBCs including B-lymphocytes that produces and secretes immunoglobulin (antibodies), and monocytes, macrophages and neutrophils monocyte.

Antibodies attach to the viralantigens, and thenmonocytes/macrophages willperform phagocytosis through Fcreceptor (FcR) within the cells anddengue virus replicates in the cells

Entry to spleen

the

Entry to the bone marrow

Recognition of dengue viral antigen infected monocyte.

on

Release of cytokines which consist of vasoactive agent such as interleukens, tumor necrosis factor, urokinase and platelet activating factor which stimulate WBC and pyrogen release

Dengue

Virus ultimately targets liver and spleen parynchemal cells where infection produces cell death

Cellular direct destruction of red bone marrow precursor cell as well as immunological shortened platelet

Hepatosplenomegaly

Thrombocytopenia

Dengue Hemorrhagic

VIII. NURSING CARE PLAN FOCUS: Increased body temperature

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: apat na araw na po ako nilalagnat, di pa po ako guagaling,as verbalized by the patient.

Hyperthermia related to increased metabolic rate as evidenced by increase in body temperature (38C).

Objective: Flushed skin Weak in appearance Teary eyes Increase in vital signs PR: 93 bpm T: 38 C R:26 BP:100/80mmHg

Short term objective: After 30 minutes of rendering appropriate nursing intervention, the patients temperature will be decreased from 38C to 37.5C or lower(within normal range).

Diagnostics: Note presence or absence of sweating as body attempts to increase heat loss by evaporation, conduction, and diffusion. Monitor and record all sources of fluid loss such as urine.

Evaporation is decreased by environmental factors of high humidity and high ambient temperature. Oliguria and/or renal failure may occur due to hypotension, dehydration, shock, and tissue necrosis. To evaluate effects or degree of hyperthermia.

Goal met. Patients temperature subsided from 38C to 37.5C.

Monitor vital signs especially temperature. Therapeutics: Dependent: Administer medications as indicated or ordered by the physician. Administer replacement of fluids and electrolytes. Independent: Perform tepid sponge bath.

To treat underlying cause.

To support circulating volume and tissue perfusion. Heat loss by evaporation and conduction. To assist with measures to reduce body temperature/restore normal body/organ function. To reduce metabolic demands and oxygen consumption.

Promote surface cooling by means of undressing/reducing clothes and removing excess blankets. Maintain Bed rest.

Educative: Discuss importance of adequate fluid intake from 1,5002000 ml per day. Instruct to increase intake of Vitamin Crich foods.

To prevent dehydration.

To boost the immune system.

FOCUS: Nose bleeding ASSESSMENT Subjective: bigla nalang pong dumugo itong ilong ko, verbalized by the patient. Objective: Irritability Epistaxis Weak in appearance pallor DIAGNOSIS Risk for injury hemorrhage related to alter clotting factor. PLANNING Short term objective: After an hour of nursing interventions, the patient will be able to demonstrate behaviors that reduce the risk for bleeding. INTERVENTION Diagnostics: Assess vital signs including BP, pulse, and respiration. Assess skin color and moisture, urinary output, level of consciousness or mentation. RATIONALE EVALUATION

To determine if intravascular fluid deficit exists. Changes in these signs maybe indicative of blood loss affecting systemic circulation or local organ function such as kidneys or brain. Note for alterations on blood. The G.I. tract(esophagus and rectum) is the most usual source of bleeding of its mucosal rigidity.

Goal me. Patient is able to demonstrate behaviors that reduce risk for bleeding.

Review laboratory data (CBC) result Assess for signs and symptoms of G.I bleeding. Check for secretions; observe color and consistency of stools or vomitus. Therapeutics: Dependent: Assist with treatment of underlying conditions causing or contributing to blood loss. Educative: Need to inform health care providers when taking aspirin and other anti-coagulanttype agents. Instruct at risk patient and family regarding:

To prevent bleeding/correct potential causes of excessive blood loss. These agents will most likely be held for a period of time prior to elective procedures to reduce potential for excessive blood loss. To prevent bleeding / correct potential causes

Specific signs of bleeding requiring health care provider notification such as prolonged epistaxis.

of excessive blood loss.

IX. DRUG STUDY Generic name: ceftriaxone sodium Brand name: Rocephin Drug Classification: Antibiotic, Cephalosporin (third generation) Dosage: 1 amp IV q 12 h, ANST (-) Indication: Urinary tract infection MECHANISM OF ACTION Bactericidal: Inhibits synthesis of cell wall causing cell death SIDE EFFECT CONTAINDICATIONS ADVERSE REACTION NURSING CONSIDERATIONS Teaching points: You may experience these side effects: stomach upset or diarrhea Report severe diarrhea, difficulty breathing, unusual tiredness or fatigue, pain at injection site. Discontinue if hypersensitivity reaction occurs.

Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence Ranging from rash to fever Pain, phlebitis Super infections, desulfiram-like reaction with alcohol

Contraindicated with allergy to cephalosporins or penicillins.Use cautiously with renal failure.

CNS: headache, dizziness, lethargy, paresthesias GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, pseudomembranous colitis, liver toxicity GU: nephrotoxicity Hematologic: Bone marrow depression decreased WBC, decreased platelets, decreased Hct. Hypersensitivity: Ranging from rash to fever to anaphylaxis; serum sickness reaction Local: Pain, abscess at injection site; phlebitis, inflammation at IV site Other: Super infections, desulfiramlike reaction with alcohol.

Generic name: paracetamol Brand name:Flugard Drug classification: antipyretic, analgesic (non opioid) Dosage: IV 1 amp now then PRN fer fever Indications: for fever MECHANISM OF ACTION SIDE EFFECT Antipyretic: reduces fever by acting directly on the hypothalamic heat-regulating center to cause vasodilation and sweating, which helps dissipate heat. Analgesic: site and mechanism action unclear. none

CONTAINDICATIONS Contraindicated with allergy to acetaminophen. Use cautiously with impaired hepatic function, chronic alcoholism, pregnancy, lactation.

ADVERSE REACTION CNS: headache CV: chest pain, dyspnea, myocardial damage when doses of 5-8 g/day are ingested daily for several weeks or when doses of 4 g/day are ingested for 1 year. GI: Hepatic toxicity and failure, jaundice GU: acute renal failure, renal tubular necrosis. Hematologic: methemoglobinemia cyanosis; hemolytic anemia hematuria; anuria; neutropenia, leukopenia,thrombocytopenia, hypoglycemia Hypersensitivity: rash, fever

NURSING CONSIDERATIONS Assessment: History: allergy to acetaminophen, impaired hepatic function. Physical: skin color, lesions, T; liver evaluation; CBC, LFTs, renal function tests.

X. DIAGNOSTIC TESTS/LABORATORY RESULTS: TESTS RBC Count Hemoglobin Hematocrit WBC RESULT 4.55 103 .30 3.8 NORMAL VALUES M=4.69-6.13x10 12/L F=4.04-5.48x10 12/L M=140-180g/L F=120-160g/L M=0.40-0.54 F=0.37-0.47 5-10x10 9/L REMARKS normal normal normal Normal

DIFFERENT COUNT : Segment Lymphocytes Monocytes .49 .46 .5 0.50-0.70 0.20-0.40 0.0-0.07 Normal

URINALYSIS RESULTS NORMAL VALUES SIGNIFICANCE

PHYSICAL: Color Transparency CHEMICAL: Specific Gravity Urobilinogen Red Blood Cells Protein pH Blood cells MICROSCOPIC: RBC Epithelial Cells A Urates/Phosphates Dark Yellow Slightly turbid Straw yellow to amber Clear 1.010 1.030 Normal Indicates abnormality

1.010 Normal 1-2 (-) 6.0 (-)

Normal Normal

02 (-) 4.8-8 (-)

Normal Normal Normal Normal

1-2 Few Few

XI. ONGOING APPRAISAL The patient is responding well to both medical and nursing intervention.

XIII. DISCHARGE PLAN (HEALTH TEACHING) Medication: Instruct IE.DR to take all the necessary medicines that the doctors prescribed. Treatment: Instruct to follow all prescribed therapeutic regimens. Clinical follow up: Instruct the patient to come back on scheduled follow up check. Diet: Advise to eat dark green leafy vegetables, rich in iron and vitamin C diet to regain strength and boost his immune system Danger Signs: Instruct the patient to seek medical advice if he is experiencing excessive nose bleeding and high-grade fever and appearance of rashes.

I.

PATHOPHYSIOLOGY ( in diagram )

Dengue infection

Antibody formation

Reinfection

Augmentation of virus multiplication

Increased vascular permeability

Reduce Platelets

Plasma Leakage

Coagulopathy

Hypovolemia

Disseminated intravascular coagulation

Shock

Severe Bleeding

Death