Luxembourg St., BF Homes International, Las Pias City 1740
College of Nursing
Patient-Centered Care Report
Dengue Fever
Paolo R. Gonzales BSN-4 September 4, 2014
1. Introduction Patient M.L. a 9 year old pediatric patient living in Las Pinas City was admitted by his mother on August 11, 2014 at LPDH ER due to chief complaint of a high-grade fever with nausea and vomiting and loss in his appetite. Patient did not yet experience serious health problems other than fever, colds, and cough. Patient had no past hospitalization. Admitting Diagnosis: Dengue Fever
2. Nursing Physical Assessment Patient M.L. is a 9 year old male. His vital signs upon the admission show as follows: BP: 90/60, PR: 68, RR: 22, T: 37.9 During my rotation upon assessment received patient awake on bed semi fowlers, incontinent with IVF inserted on left metacarpal vein, ongoing PNSS 1L X6. Patients vital signs taken and recorded as follows: T: 37.9 PR: 68 RR: 20 BP: 90/60 O2Sat: 99%.
INSPECTION: His hair is well distributed, dry, dental carries present. PALPATION: His skin is warm to touch, Capillary refill of 2 seconds, relaxed abdomen, distended bladder. Temporal pulse (normal) Radial pulse (normal) Brachial pulse (normal) PERCUSSION: Respiratory (Resonant) Gastrointestinal (Tympany, Dull) AUSCULTATION: Respiratory (Clear) Gastrointestinal (N/A) Cardiovascular (N/A)
LABORATORY DATA: HEMATOLOGY REPORT TEST NORMAL VALUE ACTUAL RESULTS FINDINGS Hemoglobin
Hematocrit
WBC
Segmenters
Lymphocytes
Platelet Count
(M) 130-180 g/L
(M) 37-39 vol%
5-10 x 10 9/L
0.60-0.70
0.20-0.30
150-450x10^g/dL 102
0.26
3.9
0.73
0.73
163 x 10^g/dL Decreased
Decreased
Decreased
Increased
Increased
Normal
TEST NORMAL VALUE ACTUAL RESULTS FINDINGS Color
Transparency
Reaction
Specific Gravity
Sugar
Protein
RBC
Pus cells Yellow Amber
Clear to slightly turbid 4.5-8
1.005-1.030
Negative
Negative
Few
Few Yellow
Clear
6.5
1.020
Negative
Negative
0-2
0-2 Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
3. Pathophysiology
Aedes aegypti viral replication
Bite from dengue mosquito
Allowing dengue virus to be inoculated in the blood stream
Virus disseminated rapidly and stimulates WBCs including B lymphocytes that produces and secretes immunoglobulins, and monocytes/macrophages, neutrophils
Risk Factors Environment Hx of dengue
Etiology Aedes aegypti
Clinical Manifestations High-grade fever Nausea and vomiting Loss of appetite Flu-like symptoms Dehydration
4. Actual Managements and Related Treatments Actual Management: IV PNSS 1L X 6 CBC Urinalysis Maintenance /Due medications CBC monitoring TPR monitoring Ideal Management: IVF Antibiotics Analgesics Appetite stimulants CBC monitoring TPR monitoring Strict I&O monitoring Increase fluid intake TSB
Medications: Paracetamol 250mg/5ml q4 Amoxicillin 375md TID
5. Nursing Care
1. Hyperthermia 2. Imbalanced nutrition, less than body requirements 3.
Nursing Problem Short-Term Goal Medium-Term Goal Long-Term Goal 1. Hyperthermia
- Patient will show normal signs of body temperature - Patient will display no further increase in temperature - Patient will maintain improved normal temperature 1. Fluid volume deficit
- Patient will be in a normal hydration State. -When assessed the patient will be show no signs of dehydration -Patient will maintain his normal oral input of fluids
2. Imbalanced nutrition, less than body requirements
-The patient will show signs of Patient will show normal caloric intake -Patients laboratory status results would meet the normal values. -Patient will maintain an adequate overall nutritional status.
6. Prioritization
Achieving the priorities of my patient starts with: 1. Hyperthermia- Lowering down or maintaining a normal temperature is important. Excessive heat buildup can do a massive damage to the patient and, in extreme cases, can be fatal. Fever is one of the most common symptoms of illness. A patient is said to be having fever if his body temperature rises above the normal range which is between 36 - 37oC. Since each individual's temperature range varies, generally, a reading above 37.2oC measured in the mouth is considered febrile. In adults, fever is usually not dangerous unless it measures 39oC or higher. Most fevers are self-limiting and usually go away in a relatively short time, usually within a few days. In fact, moderate fever (not higher than 38oC) has beneficial effects as the body adapts itself through normal physiological mechanism which strengthen the immune system. Hence, aggressively treating all fevers can actually interferes with the body's immune response. (n.d.).)
2. Fluid volume deficit - It shows that the patients input and output should be balanced to identify any fluctuations in intravascular fluid. Fluids must be given for replacement and maintenance purposes. In the febrile stage of DHF, fluid loss should be replaced with oral rehydrating salt solution. As much as 75 ml/kg body weight can be given in 4 hours. Intravenous fluid therapy is recommended when danger signs are present, especially during defervescence. Intravenous fluid therapy is recommended when danger signs are present, especially during defervescence. Meanwhile, look for other causes of shock such as bleeding, which may or may not be obvious. (n.d.).)
3. Imbalanced nutrition, less than body requirements- As client begins to increase in weight, laboratory results improve to within normal range, and monitoring is needed less frequently. Vital signs at least until stable, then daily. Repeat electrocardiogram (ECG) and laboratory tests (electrolytes, acid-base balance, liver enzymes, albumin, and others) until stable( Ulrich, S. P., Ulrich, S. P., Canale, S. W., & Wendell, S. A. (1994). Medical-surgical nursing care planning guides. Philadelphia: W.B. Saunders.)
References:
Ulrich, S. P., Ulrich, S. P., Canale, S. W., & Wendell, S. A. (1994). Medical- surgical nursing care planning guides. Philadelphia: W.B. Saunders.
Grossman, S.C. & Porth, C.M. (2014). Porth's Pathophysiology: Concepts of Altered Health States (9th ed.). Philadelphia: Lippincott Williams & Wilkins.