I.

INTRODUCTION Dengue is the most common mosquito-borne viral disease of humans that in recent years has become a major international public health concern. Globally, 2.5 billion people live in areas where dengue viruses can be transmitted. The geographical spread of both the mosquito vectors and the viruses has led to the global resurgence of epidemic dengue fever and emergence of dengue hemorrhagic fever (dengue/DHF) in the past 25 years with the development of hyperendemicity in many urban centers of the tropics.

Transmitted by the main vector, the Aedes aegypti mosquito, there are four distinct, but closely related, viruses that cause dengue. Recovery from infection by one provides lifelong immunity against that serotype but confers only partial and transient protection against subsequent infection by the other three. There is good evidence that sequential infection increases the risk of more serious disease resulting in DHF.

DHF was first recognized in the 1950s during the dengue epidemics in the Philippines and Thailand. By 1970 nine countries had experienced epidemic DHF and now, the number has increased more than fourfold and continues to rise. Today emerging DHF cases are causing increased dengue epidemics in the Americas, and in Asia, where all four dengue viruses are endemic, DHF has become a leading cause of hospitalization and death among children in several countries (WHO)

II. BIOGRAPHIC DATA Name: MFGPC Address: #20 Capitol Green Village, Tandang Sora, Quezon City Age: 12 y/o Birthday: September 5, 2001 Place of Birth: Quezon City Gender: Female Nationality: Filipino Ethnic Background: Aklanon, Bulakeyo Religion: Roman Catholic

Marital status: Single Occupation: Student (Grade 6) Date of Admission: September 3, 2013 Chief Complaint: Fever for 3 days Admitting Physician: Dr. Firmalo Admitting Diagnosis: Dengue Fever Syndrome Final Diagnosis: Dengue Hemorrhagic Fever II

III. NURSING HISTORY A. Past Health History This is the first time MFGPC was hospitalized and never experience accident crisis. According to her mother, she did not experience any childhood disease. Typical cough and colds and sometimes fever are the only health illness she had from the past. When this happen to her, her mother ask their relatives what to take since they are under medical field like doctors. She received immunizations offered by the barangay health center like BCG, DPT, OPV, Measles, Hepatitis B and MMR. She has no known allergies. She takes her vitamins but not every day because sometimes she forgets that she has to take her vitamins. When she had her 1st menstrual cycle, she also started to take iron supplement. She has no foreign travel but had local travel, in Palawan 3 years ago. A medication she is currently taking is paracetamol when her temperature is above normal. B. History of Present Illness On the first day of illness (august 31, 2013) MFGPC had developed intermittent high grade fever (39.70C) associated with on and off frontal headache with a pain scale of 5/10. Patient takes Paracetamol every 4 hours. Sept 1, since she still have a high fever, the relative of her mother told them to check for her CBC specifically platelet count. So they did, and the result was 160. Because this is still within normal range, they advice her to take more fluids and continuous monitoring and also take paracetamol for fever. She also experienced joint pain. Her grandmother massages her joints to relieve the pain. MFPGC verbalized, Mejo po nawala nun pero po masakit padin noon Sept. 2, She has no fever but still with frontal headache with a pain scale of 4/10, myalgia and dizziness, her platelet count was then became 166. So there was an

increase on platelet count. Sept 3, when they monitored her platelet count, it was already 146. This is already below normal range so they decided to admit her in Fe del Mundo Hospital. C. Family History Genogram shows that there is a history of Hypertension in the father side while in the mother side there are histories of different disease namely, Diabetes Mellitus, Heart disease, ovarian disorder and also endometrial disease. MFGPC is our patient who was diagnoses of DHF II) D. Developmental History (Pedia) MFGPC started her menstrual period when she was 11 years old. Her first menstrual period was on December 12, 2012. She stated, minsan po 1 o 2 buwan po ko hindi nagkakaroon.She feel bothered about it. It is explained that ovulation and regular menstrual period usually occur 6-14 months after menarch (Wong, 2005). When she was in a younger age she didnt want to be away from her parents. She wanted to be with them all the time. But now she wanted to be more independent so she decided to join different clubs in their school (photo journalism) and also attend district or regional competition especially academic matters. She was no difficulty when it comes to writing and speaking. She was always guided by her parents.There was a time when she was bullied by her classmates. She has 3 trusting friends. She mentioned that she dont want to be with group of girls (more than 5) because she feels like not all of them will be trustworthy. Even though she wants to be independent in doing things, she would still prefer to share her problem to her mother. There are times when she gets irritated with her brother but then sometimes they are fine. Mood swings in this age is normal. (Wong, 2005) IV. Patterns of Functioning A. Psychological Functioning 1. Coping Patterns MFGPC is a 12 year old child who is on the 6th grade. As a school age child she undergoes stress because of school works or activities, brother-sister arguments, and also peer pressure problems. When asked about how she copes up with her stress, she verbalized, Basta po nag aaral ako ng mabuti, tapos pag nag-aaway kami ni kuya manonood nalang ako at kakain,

tapos ung mga iba na nagbubully, d ko nalang pinapansin. She also mentioned that when she have difficulties on how to handle her problems she usually talk to her mother about it. In the hospital, she dont really feel stressed, she verbalized, wala naman po kasi ako ginagawa dito, buti nalang nandito si mama at buti may TV. She feels relieved and more comfortable when she is with her mom.

Interpretation: The patient way of dealing with stress is through studying harder and eating because she is having difficulty in dealing with problems. And also, her mother is a big help so she can verbalized her thoughts about things that is happening to her.

Analysis: Adolescents are having hard time in coping with different situations. They are in times of searching new identity and their task is to develop trust with others and also to themselves. And in this stage, they are also delevoping their autonomy. Also, psychosocial assessment in adolescents includes the assessment on how they interact with their parents. (Kozier and Erb; Fundamental of Nursing; 8th ed. p.385) 2. Interaction Patterns MFGPC is very close to her family especially to her family. To her older brother, even though they argue sometimes, still there are times when they are good with each other and also to her younger brother. To her friends, she verbalized, Hindi kasi ako mahilig sa madaming kaibigan, mas ok na ung konti, apat kami. Minsan kasi hindi sila napagkakatiwalaan. Her mother is always present when she needs someone to talk to. She has no difficulty in interacting with the doctors and nurses in the hospital. She verbalize, Ung mga nurse, d ko naman kasi masyado nakikita kasi naka mask. Tapos ung doctor, mababait naman Through observation, we noticed that she interacts with her mother in a polite way.

Interpretation: MFGPC knows how to interact well at her age. She interacts without feeling any hesitance or shyness. She knows how to interact in a well-mannered way. But she is having trust issue, when it comes to other people.

Analysis: At her age, the task of developing trust in others is again encountered when adolescent look for ideal persons whom they can trust and with whom they can prove trustworthy. They are having close relationship most especially, to those people who they interact every day. (Kozier and Erb; Fundamental of Nursing; 8th ed. p.385) 3. Cognitive Patterns MFGPC is able to recall past and present events and her significant others and important events in her life. She is oriented to date, time and place. She is able to read, speak and write without difficulty. She can recall remote and recent memory about herself, She has no visual or auditory impairments. His reasoning is appropriate with the questions asked to her by the student nurse and can expresses herself well by chatting with other patients and her significant others.

Interpretation: She is well oriented. She do what a normal adolescent do. Analysis: Piagets Formal operation main feature is at this stage, adolescents can think beyond the present and beyond the world of reality. They become more infomed about the world and the environment. (Kozier and Erb; Fundamental of Nursing; 8th ed. p.386) 4. Self Concept When asked about herself, she verbalized Ok naman po ako. Pag physical po eh, kontento na po ako sa sarili ko. Pakiramdaman ko kulang na ako sa dugo simula nung nag mens po ako, (Dec, 2012). She also mentioned she is bored sometimes during her stay in the hospital. She may feel weak because she is just lying on bed and she also want to go home already.

Intepretation: She perceived herself as a physically healthy individual. She just feels weak because she was confined in the hospital.

Analysis: Adolescent thinks that they are healthy physically. Their physical growth during adolescence is greatly influenced by a number of factors, such as heredity nutrition, medical care, illness, physical and emotional environment, family size and culture. (Kozier and Erb; Fundamental of Nursing; 8th ed. p.384)

5. Emotional Patterns MFGPC verbalized, Madalas Masaya ako. Masaya pag wala kaming teacher, pag nanonood ng TV at pag kainan na at pagnagkwe-kwentuhan kami ng mga kaibigan ko at minsan lokohan She is also happy that she is part of the photo journalism organization. She feels sad when jokes of her classmates are no longer funny. She verbalized, pag inaasar nila ako ung below the belt na mga joke nila. Her mother saw once about it. They call her fishda. Her mother told her classmates that is not a joke anymore. After that, MFGPCs feel happy and her classmates stop calling her fishda Interpretation: She is now entering the stage of adolescents. Her emotions depend on how the situations flow. Sometimes she is happy, and sometimes sad. When she is experiencing something undesirable she often asks for the advice of her mom because she know her mom will help her all the time. Analysis: Many adolescents experience temporary difficulty in developing a positive self-image. Adolescents who are accepted, loved, and valued by family and peers generally tend to gain confidence and feel good about them. (Kozier and Erb; Fundamental of Nursing; 8th ed. p.385)

6. Sexuality MFGPC dresses simply, pants and blouse is enough to show how girly she is. She prefers girl peers. She is comfortable talking with anyone either male or female.But it is not easy for her to trust others immediately. She had her first menstrual period on Dec, 2012, she verbalized, Pakiramdam ko pag meron ako, naghihina ako. Interpretation: She is comfortable talking to anyone. And she already recognizes different changes in her body as she enters the stage of adolescence. Being simple shows that she is a young girl. Analysis: The task of developing trust in self and others encountered when adolescents look for ideal persons whom they can trust. Adolescents are usually concerned about their body, skin, their appearance and their physical abilities. Hairstyling, skin care, and clothes become very

important. The development of stable identity is difficult because of adolescents dramatic body changes. (Kozier and Erb; Fundamental of Nursing; 8th ed. p.384)

7. Family Coping Patterns MFGPC has a good relationship with her family. She verbalized, Masmadalas kaming bati ng kuya ko, tapos lagi kaming bati ng bunso namin. Her mother told us that she is obedient to her parents and grandparents. When she has a problem her family support and guide her. Interpretation: Sometimes, in adolescent stage, they are more on peers than families. But since MFGPC is still on the first part of the adolescent stage she is more focused on the presence of her family. She feels loved and supported with her family. Analysis: Adolsence still need guidancefrom their parents, although they appear to neither wat it or need it. However, adolescents need to know that their parents care about them and that their parents still want to help them. Restrictions and guidance need to be presented an a manner that makes the adolescents feel loved . (Kozier and Erb; Fundamental of Nursing; 8th ed. p.386) B. Socio-Cultural 1. Cultural Patterns MFGPCs religion is Roman Catholic. With regards to her belief on a healthy person, she verbalized, yung walang sakit at saka yung umiinom ng vitamins. She takes a bath once a day and sometimes, twice a day. She brushes her teeth 2-3 times a day. Whenever she has colds, she drinks a lot of water and when she has a fever, she does not self-medicate. As verbalized by the mother, yung relative kasi namin doctor, tas puro naman sila in line sa medicine. The patient also does not smoke or drinks alcohol.

Interpretation: Her concept of health depends on what she is doing to maintain a healthy body.

Analysis: Culture and social interactions also influence how a person perceives, experiences and copes with health and illness. Each culture has ideas about health and these are often transmitted

from parents to children. Adolescence are highly imaginative and idealistic. They consider thinks that do not exist but that might be and consider things could be or ought to be. (Kozier and Erb; Fundamental of Nursing; 8th ed. p.301-302)

2. Significant Relationship The patient considers her family as her significant persons. According to MFGPC, her relationship with her family is good. As verbalized by the client, Palagi kaming nag-uusap at saka di kami gaanong nag-aaway. At saka okay naman yung communication namin sa isat isa. Whenever she has problems, she tells it to her dad, mom and relatives. Di ko sinasabi sa friends ko yung mga problems ko kasi ipagkakalat lang naman nila, as verbalized by MFGPC. They also fix her problems by talking it out properly. With regards to her role in their family, she describes herself as an Ate. She follows the instructions of her mother and she helps her in doing the household chores. As verbalized by her mother, Hati kami sa gawaing bahay kasi siya lang yung babae eh. Yung panganay at bunso kasi lalaki. Siya rin yung inuutusan ng Lola niya.

Interpretation: Communication is important to her in order for her to voice out what she feels and she can see her family as one whom she can trust.

Analysis: In their search for a new identity, adolescents have to process many of the previous stages of development. The task of developing trust in self and others is again encountered when adolescents look for ideal persons whom they can trust and with whom they can prove trustworthy. (Kozier and Erb; Fundamental of Nursing; 8th ed. pp.384-385)

3. Recreational Pattern Her hobby is playing doll house with her sibling. She considers walking as her exercise because she walks from their house going to their school. Malapit lang kasi yung bahay sa school namin. Mga 10 minutes siguro akong naglalakad tapos jeep, as verbaliz ed by the client. Whenever she is at school, what she does is study and attends journalism organization. While at home, she takes a nap then afterwards fetches her sibling at their school.

Interpretation: The client is active in school and studies hard. She joined an organization in which it involves taking pictures.

Analysis: Adolescents usually select their own areas for learning; they explore interests from which they may evolve a career plan. Study habits and learning skills developed in adolescence are used throughout life. (Kozier and Erb; Fundamental of Nursing; 8th ed. p.386) 4. Environment MFGPC lives in a subdivision. She describes their community as quiet. As verbalized by the patient, parang walang tao. According to her mother, their house was converted to a compound type. Their house is well lighted and well ventilated. Minsan nga di na kami gumagamit ng ilaw kasi ang laki ng bintana namin, as verbalized by her mother. Cockroach and rats are also present in their house. They spray insecticides into cockroaches and poison the food of the rats. Fumigation is done in their community whenever it is only required and when there are presence of dengue cases. Collection of garbage in their community is also done three times a week. Non-biodegradable is collected once a week and biodegradable is collected two times a week. They also have enough resources with regards to medicine because they have relatives who are in line with medicine.

Interpretation: They are aware on the vectors present in their environment and how they can eliminate it because it can cause harm to their health. They also practice the segregation of garbage.

Analysis: People are becoming increasingly aware of their environment and how it affects their health and level of wellness. (Kozier and Erb; Fundamental of Nursing; 8th ed. p.301)

5. Economic The father of MFGPC has his own talyer while her mother works in a research company in Makati. Their income is only enough for their expenses. According to her mother, she prioritizes their needs as food being the first, followed by water and electricity, health,

education, clothing and shelter as being the last. As verbalized by her mother, halos lahat kasi sa pagkain napupunta at saka sa mga binabayaran. Yung education naman nila, okay lang kasi sa public school sila nag-aaral. And then sa clothes, hand me down. Di rin naman namin priority yung shelter kasi sa amin naman ito at wala kaming binabayaran. When asked if they experience financial problems, her mother verbalized, Palagi. Kasi di naman kaming pwedeng gumastos ng higit pa dun sa kinikita naming kasi kailangan sapat lang. What they just do is budget properly their income.

Interpretation: Their income is enough to satisfy their needs and food is their priority. They are also aware on how to budget their income for the food and other necessities. Analysis: An individuals standard of living (reflecting, occupation, income and education) is related to health, morbidity, and mortality. Hygiene, food habits and the propensity to seek health care advice and follow health regimens vary among high-income and low-income groups. (Kozier and Erb; Fundamental of Nursing; 8th ed. p.301)

C. Spiritual Pattern 1. Religious Beliefs and Practices MFGPCs belongs to Legion of Mary, in which ever Saturday; she goes to church with her grandmother. And then every Sunday, they attend mass. MFGPC sees God as our creator. As verbalized by the client, Si God ang naglikha sa atin at siya ang gumawa ng lahat. She also said that her faith and relationship with God is good because she prays to Him every day. She also prays that all the blessings would go to her.

Interpretation: The client was influenced by her grandmother who always goes to church to attend an organization and serves God. Analysis: According to Fowler, the adolescent or young adult reaches the synthetic-conventional stage of spiritual development. As adolescents encounter different groups in society, they are exposed to a wide variety of opinions, beliefs and behaviors regarding religious matters. (Kozier and Erb; Fundamental of Nursing; 8th ed. pp.386-387) 2. Values

According to her mother, MFGPC follows and obeys them. Whenever they would ask her to do something, she would always follow. She is also taught on how to be not self centered and she is open to all the problems that they are facing. She also studies hard and gives her best at school.

Interpretation: MFPGC is very obedient and follows the instructions of her parents. She also believes that everything that she does is for her own good.

Analysis: According to Kohlberg, the young adolescent is usually at the conventional level of moral development. Most still accept the Golden Rule and want to abide by social order and existing laws. (Kozier and Erb; Fundamental of Nursing; 8th ed. p.386) V. ACTIVITIES OF DAILY LIVING

Activities of Daily Living Before Admission During Admission Interpretation and Analysis Nutrition The patient eats 2-3 times a day. She sometimes skipped her breakfast or lunch. The patient said that she usually eat rice, luncheon meat. The patient prefers to eat meat in her meals than vegetables. She sometimes eat fruits. Her favorite food is The patient is in a regular diet except for dark colored foods. The patient eats three times a day. She consumes 1 cup of rice every meal. In her breakfast, she usually eats bread or lugaw. Her meals are complete with fruits, fish and meats. The patient stated that there Alteration in the clients diet are often needed to treat a disease process to prepare for a special examination or surgery, to increase or decrease weight, to restore nutritional deficits or to allow an organ to rest and promote healing.

are no changes in appetite. Diets are modified in The patient drinks 4-6 one or more of the

adobo. She also said that she does not eat junk foods. The patient drinks 8 glasses of water a day. When it comes to appetite the patient has no problem. The patients mother verbalized. Sa kanilang magkakapatid, siya ang pinakamatakaw. Yong baon niya halos sa pagkain napupunta.

Liters of water a day. The patients mother verbalized Inadvise kasi ng doctor na painumin siya at least 3L/day kaso napapasobra.

following aspects: texture, kilocalories, specific nutrients, seasonings, or consistency. The client must understand the diet and also develop a healthy positive, attitude toward it. Assisting clients and support persons with special diets is a function shared by the dietician or nutritionist and the nurse. (Pearson prentice hall, Fundamentals of Nursing by Kozier and Erb, 8th edition, vol.II, page 1260, 1262.)

The patient experienced a diet modification. Before, she is on regular diet but during her admission, she was advised by her physician to eat except dark-colored foods to monitor bleeding

tendencies. Her diet is controlled compared than before. Her fluid intake is also increased due to platelet depletion.

Elimination

The patient urinates at least 4 times a day with no difficulty. According to the patient, the color of her urine is sometimes yellowish or clear white.

The patient urinates from time to time due to increased fluid intake. Her urine output is 4-6 L/day. On her 3rd day, her urine output is 3650 in just 12 hours. According to the patient her urine is clear and did not difficulty

The excretory function of the kidney diminishes with age, but usually not significantly below normal levels unless a disease process intervenes. With age, the number of functioning nephrons decreases to some

The patient defecates every other day with no difficulty. The consistency of her stool usually is formed, not soft nor hard. According to the patient, the usual color of her stool is brown.

while urinating.

The patient defecates once degree, impairing the a day during her admission. On her 3rd day in the hospital, the patient said that she had a difficulty defecating and reports pain. She described the consistency of her stool is hard. The color of her stool is black due to iron intake. The patient said that he feels uneasy to urinate or kidneys filtering abilities. Normally, kidneys produce urine at a rate of approximately 1,500 ml per day. The frequency of defecation is highly individual, varying from several times per day to two or three times per week.

defecate because of the IV Infusion.

(Kozier and Erbs Fundamentals of Nursing 8th edition Volume 2 page 1288, 1292, 1325) The patients urination pattern is not the same before and during admission since her fluid intake is increased. Her defecation pattern is changed may be because of her medical condition and the food and water intake during her confinement as well. Patient also verbalized her concern with regards to her elimination.

Exercise

The patient considered walking as an exercise. She walks from their house to school for 10 minutes. Since she is the only daughter, she is the

The patient stays on her bed the whole day. The

Exercise is recognized as a lifetime endeavor

patient verbalized, Ayaw that is essential for ako payagan ni mama na lumabas para maglakadlakad. The patient is always in her room watching T.V., energetic, active and healthy living. The benefits of exercise have been linked to many physiologic and

one who helps her mother in doing household chores like washing the dishes, cleaning the house and sweeping the floor. But he revealed that she does not have a routine or regular exercise.

eating and sleeping.

psychological responses, from a reduced feeling of stress to an increase sense of well-being. Exercise strengthens the heart, lungs, and blood vessels to prevent heart disease, keeps the joints flexible, and helps many people deal with sad or unhappy feeling.

There are changes in terms of activity and exercise before and during her admission. During her admission, her lifestyle became more sedentary than before may be due to the patients condition.

Hygiene

The patient takes a bath once or twice a day. She brushes her teeth two to three times a day. The patient said that she often visits a dentist

During the admission, her mother is assisting her to sponge bath. She changes her clothes every day. The patient is also brushing her teeth twice a day in the morning and evening.

The individual should take a bath, brush his teeth, trim his nails daily and get a proper haircut to improve one's self-image. (Kozier and Erb,

for dental check-up. As she verbalized, Pumupunta lang kami pag sumasakit ang ngipin ko. Takot kasi ako. She also regularly trims her nails.

Fundamentals of Nursing 7thEd.,Pearson 2007, p. 697) Bathing removes accumulated oil, perspiration, dead skin cells, and some bacteria. Bathing also produces a sense of well-being. It is refreshing and relaxing and frequently improves morale, appearance, and selfrespect. Certain clients are prone to oral problems because of knowledge or the inability to maintain oral hygiene. Proper diet and tooth and mouth care should be evaluated and reinforced to prevent tooth decay and periodontal disease. (Fundamentals of Nursing by Kozier and Erb, vol. II, pages 765768)

There are changes in terms of the hygiene of the patient. She became dependent in taking care of herself with the assistance of significant other.

Substance Use

The patient does not smoke. She is also not drinking alcohol. Although she is practicing self medication.

The patient still does not Smoking and drinking smoke and also does not alcohol beverages are drink alcohol. considered as one of the substance abuse. Substance abuse is a major threat to the health of adults. Prolonged use can lead to physical and psychologic dependency and subsequent health problems. Smoking can lead to diseases such as lung cancer and cardiovascular disease. (Fundamentals of Nursing by Kozier and erb, vol. II, pages 396)

The patient has no vices even before hospitalization and is

not under substance abuse. Sleep and Rest Before admission, the patient usually sleeps at 10 in the evening or sometimes 12 in the midnight due to school errands and wakes up at 5am. She The patient had disrupted sleeping pattern during her confinement. She has 6-12 hours of sleep. Sometimes she sleeps at 10 in the evening and wakes up at 10 in the stated, Gumigising ako pag iinom ng tubig, pag papalitan yung swero ko. The individual should sleep for at least 6-8 hours a day, sleep and rest implies calmness, relaxation without emotional stress. Healthy individuals who obtain less sleep than they need will experience sleepiness and fatigue during daytime hours. Individuals may

usually has 6 hours of morning. As the patient sleep and sometimes sleeps in the afternoon for 4 hours

after school. She does May mga pumapasok din not have any rituals before sleeping. She does not have any difficulty sleeping. The patients mother verbalized, Siya yong tipo na masandal, tulog. kasing nurses kaya

paputol-putol. During the develop attention and day, she is also taking naps. concentration deficits, distractibility, reduced motivation, fatigue, and malaise. (Kozier and Erb, Fundamentals of Nursing 7thEd.,Pearson 2007, p. 1115)

There are changes on her sleeping pattern before and during her hospitalization. Her sleeping time becomes longer and disrupted

due to her environment and medication process. The patient doesnt engage to any form of sexual activity yet.

Sexual Activity

None

Sexual health is an individual and constantly changing phenomena falling within the wide range of human sexual thought, feelings, needs, and desires. (Kozier and Erbs Fundamentals of Nursing 8th edition Volume 2 page 1023)

The patient has no sexual activity.

VI. Physical Assessment General Appearance and Mental Status Assessment Height: 145.5 cm Weight: 45.5 kg BMI: 21.36 Interpretation: Within Normal. Normal BMI for Asian Women is 18.5-23.9.

Vital Signs: Temperature:36.1 C (via axilla)

Pulse Rate: 79bpm Rhythm: regular Volume/Amplitude: normal Respiratory rate: 20cpm Rhythm: regular Depth: shallow Effectiveness: effortless breathing

Blood Pressure: 100/70 mmHg Assessment Body Built Normal Findings Proportionate, varies with lifestyle (Kozier&Erb, 2008) Actual Findings She has a body built for her age. The body parts appear to be equal and proportional with firm and well-developed bilateral muscles. There was no noted presence of any deformity. Posture and Gait Erect posture and purposeful gait communicate a sense of well-being. Posture and gait may be altered by many physical factors such as pain, drugs and fracture, (Kozier&Erb, 2008) Hygiene and Grooming The client is clean and groomed appropriately (Weber & Kelly, 2007). The patient was dressed in her t-shirt and pajamas; there was no presence of body odor. Clients hair was neatly tied in a ponytail. The nails are clean and cut short. Signs of Distress (facial and postural) Signs of health or illness Healthy appearance. Lips should be Uniform pink color. Soft, moist, smooth in texture and symmetry of contour. (Kozier&Erb, 2008) It was observed that she has dry lips. In Deviation No distress noted (Kozier&Erb, 2008) Patient smiled after being greeted by the student Normal nurses. She was calm and collected while being interviewed. Normal Patient was seen lying on bed (with head of bed slightly elevated) wherein she stated that whenever she stood up, she experiences pain in her legs that she verbalized, parang namamanhid lang naman..pag tumatayo ako dun medyo masakit. Deviation from Normal Analysis Normal

addition, the patient seemingly has circles under from her eyes (but was stated that this was a physical feature or inborn trait that she got from her parents.) It was observed that she was frequently yawning during the interview. Normal

Attitude

Client is cooperative and purposeful in his or her interactions with others(Weber & Kelly, 2007);able to follow instructions (Kozier&Erb, 2008)

Patient was able to appropriately divulge her answers to the questions asked. She also established good eye contact and was cooperative during the conversation.

Normal

Mood and Responses

Appropriate to situation (Kozier&Erb, 2008)

Responses were direct and satisfactory; she didnt manifest any anxiety or urgency when the interview was conducted.

Normal

Quality and Quantity of Speech

Understandable,

She was able to respond in a moderate tone of

Normal

moderate pace; clear tone vocice and in an understandable manner using and inflection; exhibits thought association (Kozier&Erb, 2008) Tagalog as the medium of communication. She also spoke in a fluentand clear manner.

Relevance and Organization of Ideas

Logical sequence; makes

The patient was able to understand the

Normal

sense; has sense of reality questions easily and was not hesitant to answer (Kozier&Erb, 2008) or speak about certain topics during the conversation; she responded in a logical manner and was the answers that she verbalized were related to the questions asked.

Level of

Alert and oriented to

The patient was aware of the reason why she was admitted to the hospital and was also aware

Normal

Consciousnes what is happening; s (LOC)

responds to questions and of her current state. In addition, when asked of interacts appropriately. (Weber & Kelly, 2007). current location, the time and date, client answered correctly; the patient was able to respond and interact appropriately.

Areas assessed ( or Test Performed)

Technique Used

Normal Findings

Actual Findings

Analysis

I. Skull

Inspection

Rounded (normocephalic and symmetric, with frontal, parietal, and occipital prominence) ; smooth skull contour [Krozier&Erbs Fundamentals of Nursing, 8th Edition].

The skull is round, smooth and symmetric without any unusual bulging or prominence.

Normal

Palpation

Smooth, uniform consistency; absence of nodules or masses [Krozier&Erbs Fundamentals of Nursing, 8th Edition].

Skull is hard and Normal smooth with no palpable nodules and masses.

II. Hair and Scalp Scalp Inspection Scalp is clean and dry. Sparse dandruff may be visible [Weber & Kelly, Health Assessment in Nursing, 3rd Edition] Small flakes of dandruff are barely evident in the scalp but redness and lesions are not seen on the scalp surface, which is lighter than facial skin color. Hair Inspection Evenly distributed, thick, silky and resilient hair, no infection or infestation [Krozier&Erbs Fundamentals of Nursing, 8th Edition]. Hair doesnt easily break or fall when parted and is long, thick, and black in color; there are no notable infestations. III. Face Normal Normal

Face

Inspection

Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds; symmetric facial movements [Krozier&Erbs Fundamentals of Nursing, 8th Edition].

The face has an oval appearance with slight asymmetric features but exhibited symmetric movements; facial skin is characteristically dry but there are no visible pimples or redness.

Normal

IV. Eye Structures and Visual Acuity a. Eyebrows Inspection Hair evenly distributed; skin intact; eyebrows symmetrically aligned; equal movement [Krozier&Erbs Fundamentals of Nursing, 8th Edition]. Eyebrows are black, thick, and curved downward, with evenness in hair distribution; lie at the orbits of the eye and is equal both in movement and in length. b. Eyelashes Inspection Equally distributed; curled slightly outward [Krozier&Erbs Fundamentals of Nursing, 8 Edition].
th

Normal

The clients eyelashes are short, thin and sparse but is

Normal

evenly distributed over the eyelids and are curved outward along the lid margins. c. Eyelids Inspection Skin intact; no discharge ; no discoloration; lids close symmetrically No redness, swelling or lesions seen on the skin of both Approximately 15 to 20 involuntary blinks per minute When lids open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered [Krozier&Erbs Fundamentals of Nursing, 8th Edition]. eyelids; both upper and lower eyelids of the eyes close easily and meet completely at the same time upon blinking. Normal

d. Pupils

Inspection

Black in color; equal in size; normally 3 to 7 mm in diameter; round, smooth border, iris flat and round

Pupils are equally round and reactive to light and accommodation

Normal

Illuminated pupil constricts (direct response); Nonilluminated pupil constricts (consensual response)

(PERRLA) The pupils are black and round with a regular border centered

Pupils constrict when looking at near object; pupils dilate

in the iris. Both pupils constrict

when looking at far object; pupils converge when near object is moved toward nose[Krozier&Erbs Fundamentals of Nursing, 8th Edition].

and dilate at the same time when a light is shun or upon looking at near object and when the light is removed respectively.

V. Ears and hearing a. Auricles Inspection

Color same as facial skin; symmetrical ; auricle aligned with outer canthus of eye, about 10 from vertical [Krozier&Erbs Fundamentals of Nursing, 8 Edition].
th

The skin of the auricle is smooth and the same as that of the facial skin; it is aligned with outer canthus of each eye and within a 10degree angle of the vertical position.

Normal

Palpation

Mobile, firm, and not tender; pinna recoils after it is folded [Krozier&Erbs Fundamentals of Nursing, 8th Edition].

Pinna was able to recoil without delay and is firm and non-tender when palpated.

Normal

b. Normal voice Inspection tone

Normal voice tones audible [Krozier&Erbs Fundamentals of Nursing, 8th Edition].

The client heard the sounds clearly and was able to repeat all the sequences of words being

Normal

said, c. Watch tick test Inspection Able to hear in both ears [Krozier&Erbs Fundamentals of Nursing, 8th Edition]. Both of the clients ears heard the ticking of the watch with no difficulty. VI. Nose and Sinuses a. External nose Inspection Symmetric and straight No discharge or flaring Uniform color [Krozier&Erbs Fundamentals of Nursing, 8th Edition]. External nose is smooth, symmetrical and is aligned at the medially. Color is the same as the rest of the face. Palpation No tenderness; no lesions [Krozier&Erbs Fundamentals of Nursing, 8 Edition].
th

Normal

Normal

The external nose is nontender and no lesions and swelling are present.

Normal

b. Patency of nasal cavities

Inspection & palpation

Air moves freely as the client breathes through the nares [Krozier&Erbs Fundamentals of Nursing, 8th Edition].

The client is able to breathe through both of the nares without difficulty and obstruction while occluding one nares one at a time.

Normal

VII. Mouth and Oropharynx a. Outer lips Inspection Uniform pink color (darker e.g. bluish hue in Mediterranean people and dark-skinned people) Soft, moist, smooth texture Symmetry of contour Ability to purse lips [Krozier&Erbs Fundamentals of Nursing, 8th Edition]. c. Teeth and gums Inspection 32 adult teeth Smooth, white, shiny tooth enamel Pink gums (bluish or brown patches in dark-skinned clients) Moist, firm texture to gums No retraction of gums (pulling away from the teeth) [Krozier&Erbs Fundamentals of Nursing, 8th Edition]. d. Tongue Inspection Central position Pink color (in dark clients, with brown pigmentation on tongue borders); moist, slightly rough; thin whitish coating Smooth, lateral margins; no lesions Raised papillae(taste buds) The tongue is pink, moist, and is positioned at the center, moderate in size with papillae present and without lesions. It is able to Normal Client has 28 teeth which are Deviation from The lips are pink Deviation but she has a dry lips. from Normal

characteristically Normal white with smooth surfaces. Has dental carries in right lower molar teeth.

move freely Moves freely; no tenderness without difficulty. Smooth with no palpable nodules [Krozier&Erbs Fundamentals of Nursing, 8th Edition]. VIII. Posterior Thorax a. Posterior Thorax Inspection Anteroposterior to transverse diameter in ratio of 1:2 Chest symmetric [Krozier&Erbs Fundamentals of Nursing, 8th Edition]. The ratio of the Anteroposterior to transverse diameter is 1:2 and chest deformities are not present b. Spinal alignment Inspection Spine vertically aligned; Spinal column is straight, right and left shoulders and hips are at same height [Krozier&Erbs Fundamentals of Nursing, 8th Edition]. The spine is aligned vertically and the shoulders and hips are proportioned; there are no spinal deformities or deviations. XVII. Musculoskeletal system Muscles Inspection Equal size on both sides of the body No contractures No tremors Muscles are equal on both sides of the body. No Normal Normal Normal

[Krozier&Erbs Fundamentals of Nursing, 8th Edition]. Palpation Normally firm Smooth coordinated movements Equal strength on each body side

tremors are seen

Muscles have equal strength on each side of the body and exhibited coordinated movements.

Normal

Skeletal Bones

Inspection

No deformities [Krozier&Erbs Fundamentals of Nursing, 8th Edition].

No deformities seen. Client doesnt feel pain upon palpation and no redness.

Normal

Palpation

No tenderness or swelling [Krozier&Erbs Fundamentals of Nursing, 8th Edition].

Normal

Joints

Inspection & Palpation

No swelling; no tenderness, swelling, crepitation, or nodules Joints move slowly Varies to some degree in accordance with person s genetic makeup and degree of physical activity. [Krozier&Erbs Fundamentals of Nursing, 8th Edition].

The joints are non-tender and no swelling are present and moves with ease.

Normal

VII. LABORATORY AND DIAGNOSTIC EXAMINATIONS RESULT

LABORATORY TESTS INTRODUCTION Laboratory data is a key element of the safety profile for the drug agent being studied. For blood components and composition, human blood is made up of about 45% cellular components (primarily Red Blood Cells, White Blood Cells and platelets) and 55% fluid (plasma). The Urinalysis group is the test involving components of the urine. BLOOD COMPONENTS (Hematology) Most commonly ordered blood tests. It is the calculation of the cellular (formed elements) of the blood.

Components Hemoglobin

Normal findings M: 14.0 -17.0 g/dL F: 120 150 g/dL

Actual findings 14.3 g/dL

Interpretation Normal

Hematocrit

M: 42 50% F: 36 - 46%

41.0

Normal

RBC Count

M: 4.5-5.0 F: 4.0-4.5x106/L

4.83

Increased Erythrocytosis is an overabundance of red blood cells, resulting in increase blood viscosity, reduced flow rates, and, if

severe, plugging of the capillaries. Relative erythrocytosis results from decreased plasma volume, such as that caused by dehydration, diuretics and burns. (Essentials of Anatomy &Physiology 6th edition by R.R. Seeley, T.D.

Stephens and P. Tate, p.316) WBC Count 4.5-11.0x103/L 3.72 Slightly Decreased Leukopenia is a lower than normal WBC and often indicates decreased production or destruction of the red marrow. Radiation, drugs, tumors, viral infections, or deficiency of the vitamins folate or B12 can cause leucopenia. (Essentials of Anatomy &Physiology 6th edition by R.R. Seeley, T.D. Stephens and P. Tate, p.315-316)

Neutrophils

36-66%

24

Decreased Neutrophils are the type of white blood cells that fight against bacteria and destroy the harmful substances in the blood stream. Any decrease of the neutrophils blood cells can lead to serious illnesses.

Lymphocytes

22-40%

61

Increased Dengue infections are characterized by an increased number of atypical lymphocytes In addition, an increase in numbers of B-cells and a decrease in numbers of Tcells (most likely due to serum anti-T-cell antibodies) has been reported in DHF (Malavige, G.N., et al, 2004)

Monocytes

4-8%

14

Increased An increased percentage of monocytes may be due chronic inflammatory

disease, parasitic infection, Tuberculosis, viral infection (for example, infectious mononucleosis, mumps, measles, dengue)(Dugdale, D.C., 2011. Blood Diferential).

Platelets

150-400x103/L

72

Decreased Thrombocytopenia is a condition in which platelet count is greatly reduced, resulting in chronic bleeding through small vessels and capillaries. (Essentials of Anatomy &Physiology 6th edition by R.R. Seeley, T.D. Stephens and P. Tate, p.317)

IX. PATHOGENESIS

Predisposing Factors: -tropical Island (Philippines)

Precipitating Factors: - Environmental condition - Immunocompromise - Mosquito carrier dengue virus

Aedes Aegypti 8 12 days of viral replication on mosquito salivary glands

Portal of entry (skin) from mosquito bite

Allow dengue virus to be inoculated towards the circulation/blood Incubation period: 4-7 days

Virus disseminated into the blood and stimulates WBC including B lymphocytes that produces and secrets immunoglobulins (antibodies) and monocytes, neutrophils

Antibodies attach to viral antigen and the monocytes will perform phagocytosis through receptor within the cells of dengue virus replicates in the cell.

Entry to Spleen Recognition of dengue viral antigen on infected monocyte

Entry to bone marrow

Release cytokines which consist of vasoactive agent such as platelet activating factors which stimulate WBC pyrogen release

DENGUE FEVER SYNDROME Fever, Body aches, headache Nausea and vomiting Severe abdominal pain and tenderness Liver may be enlarged

CONTINUATION OF PATHOGENESIS:

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

Thrombocytopenia Sept 3 146 platelet Sept 5 72 platelet

Dengue Hemorrhagic Fever

Increase number and size of the pores in the capillaries which leads to a leakage of fluid from the blood by the interstitial fluid (capillary leakage)

Pleural Effusion

Ascites

Complication: Intense bleeding Shock Pulmonary edema Very low BP Liver cirrhosis Death

X.

ECOLOGIC MODEL

A. Hypothesis

Dengue hemorrhagic fever is a severe, potentially deadly infection spread by mosquitos, mainly the species Aedes aegypti. In the case of our patient, she has DHF probably due to the environmental factors causing from exposure to the mosquito infected by the virus. This lever model used predicts the cause of illness rather than showing the promotion of wellness. Hence, it is a fact that agent, host, and environment are interrelated to each other whether to promote wellness or factors that cause illness; health is an ever changing state. The Lever model shows the relationship among the agent, host and environment which also determine that their imbalance may lead to an occurrence of a disease.

B. Predisposing Factors / Precipitating Factors

HOST Female 12 years old Filipino

AGENT Bite of infective Aedes (day-biting

ENVIRONMENT Physical Climate Environmentduring rainy

mosquito, Aegypti mosquito)

season the incidence of contracting higher dengue is its

because

mosquito vector is able to breed more rapidly during this period. Biologic Environment living environment of

man which consists of animal, plants and fellow human-being.

Agent

Environment

Host

ECOLOGIC MODEL: THE LEVER

C. Analysis

The lever model is used to show the relationship between the host, agent and the environment and to determine if there is an imbalance between the three (3) predisposing / precipitating factors that may lead to an occurrence of disease.

The agent-host-environment model is primarily used in predicting illness rather than promoting wellness, although identification of risk factors that result from the interaction of agent, host and environment are helpful in promoting and maintaining health. Because each agent-host-environment factors constantly interacts with others, health is an ever changing state. Health is seen when all three elements are in balance while illness is seen when one, two or all three elements are not balance. (Fundamentals of Nursing by Kozier 2004)

D. Conclusion

We therefore conclude that our patient is suffering from DHF due to the bite of mosquito infected by the virus called Aedes agypti. E. Recommendation

If positive from dengue: Because Dengue hemorrhagic fever is caused by a virus for which there is no known cure or vaccine, the only treatment is to treat the symptoms. A transfusion of fresh blood or platelets can correct bleeding problems. Intravenous (IV) fluids and electrolytes are also used to correct electrolyte imbalances. Oxygen therapy may be needed to treat abnormally low blood oxygen. Rehydration with intravenous (IV) fluids is often necessary to treat dehydration. Supportive care in an intensive care unit/environment. There is no vaccine to prevent dengue fever. Use personal protection such as fullcoverage clothing, mosquito nets, mosquito repellent containing DEET (brand of diethyltoluamide, a colorless oily liquid with a mild odor, used as an insect repellent). If possible, travel during times of the day when mosquitos are not so active. Mosquito abatement (control) programs can also reduce the risk of infection. Eradication of mosquitoes by removing breeding places. XI. PRIORITIZED LIST OF NURSING PROBLEMS PROB ID & PRIO PROBLEMS IDENTIFIED AND CUES Risk for Bleeding related to Decreased platelet count. Cues: Subjective data/cues: No subjective cues 1st - This nursing diagnosis was the first priority because patient maybe at risk for a decrease in blood volume that may compromise health. This is an actual problem but Objective data/cues: maybe life threatening if not given an actual intervention. >Platelet count of 72 (normal value: 150-400x103/L) as of September 5, 2013 RANK JUSTIFICATION

>Vital Signs: T-36.1 C

PR-79bpm RR-20cpm BP-100/70 mmHg Disturbed sleep pattern related to interruption for therapeutic monitoring by health care Cues: Subjective: Gumigising siya pag iinom ng tubig, pag papalitan yung swero niya. May mga pumapasok din kasing nurses kaya paputol-putol. 2nd Disturbed sleep pattern is defined as, time limited disruption of sleep. The problem concerns the physiologic needs of Maslows hierarchy of needs. The problem is highly modifiable since the resources needed to address the problem are available. Sleep disturbance leads to a Objective: -sleepy during the interview -frequent yawning disruption of daytime function. This problem does not threaten the patients life and if the problem is addressed. Thus, being the 3rd to prioritized.

If positive from dengue: Because Dengue hemorrhagic fever is caused by a virus for which there is no known cure or vaccine, the only treatment is to treat the symptoms. A transfusion of fresh blood or platelets can correct bleeding problems. Intravenous (IV) fluids and electrolytes are also used to correct electrolyte imbalances. Oxygen therapy may be needed to treat abnormally low blood oxygen. Rehydration with intravenous (IV) fluids is often necessary to treat dehydration. Supportive care in an intensive care unit/environment. There is no vaccine to prevent dengue fever. Use personal protection such as fullcoverage clothing, mosquito nets, mosquito repellent containing DEET (brand of diethyltoluamide, a colorless oily liquid with a mild odor, used as an insect repellent). If possible, travel during times of the day when mosquitos are not so active. Mosquito abatement (control) programs can also reduce the risk of infection. Eradication of mosquitoes by removing breeding places.