PAMANTASAN NG LUNGSOD NG PASIG Alcalde Jose St.

, Kapasigan, Pasig City COLLEGE OF NURSING

In partial fulfillment in our Related Learning Experience

A Case Study of

DENGUE HEMORRHAGIC FEVER

(DHF)
STUDENT STAFF NURSES

LUNGAN, Aryan Tereza C. MENDOL, Jessica A. ACEVEDA, Keofome L.

STUDENT HEAD NURSE

CLINICAL INSTRUCTOR

Maam Josefina R. Maquiling

December 14, 2010 (TUESDAY)

PEDIA WARD

INTRODUCTION

The purpose of the study is to be familiarized with Dengue Hemorrhagic Fever (DHF); its transmission, disease process, signs and symptoms and most especially on how this can be treated or prevented. Dengue hemorrhagic fever (also called H-fever, Breakbone or Dandy fever) is a severe, potentially deadly infection spread by certain species of mosquitoes (Aedes aegypti). Aedes aegypti, the transmitter of the disease, is a day-biting mosquito which lays eggs in clear and stagnant water found in flower vases, cans, rain barrels, old rubber tires, etc. Four serotypes of dengue viruses (1, 2, 3, and 4 Group B Arboviruses) are known to cause dengue hemorrhagic fever. There are three other arboviruses that have been identified with dengue-like diseases namely Chikungunya, Onyong nyong and West Nile fever. Dengue hemorrhagic fever occurs when a person catches a different type dengue virus after being infected by another one sometime before. Prior immunity to a different dengue virus type plays an important role in this severe disease. The Department of Health warned the public about the rising number of dengue cases in the country, which reached 11,803 cases from January 1 to March 27, 2010. The DOH said the number of dengue cases is 61% higher than the 7,335 cases recorded during the same period last year. Dr. Eric Tayag, head of the DOH National Epidemiology Center, said the El Nio phenomenon could have something to do with the increase in dengue cases. He said the number of dengue cases also shot up in 1998 when the El Nio phenomenon was felt in the country. Sources 1. Infected persons the virus is present in the blood of patients during the acute phase of the disease and will become a reservoir of virus, accessible to mosquitoes which may transmit the disease. 2. Standing water within the household and premises are usual breeding places. Incubation Period 4- 6 days (minimum=3days; maximum=10days) Period of Communicability

Unknown. Presumed to be on the 1st week of illnesswhen virus is still present in the blood. Susceptibility, Resistance and Occurrence All persons are susceptible. Both sexes are equally affected. Age groups predominantly affected are the preschool and school age. Adults and infants are not exempted. Peak age affected 5-9 years. Occurrence is sporadic throughout the year. Epidemic usually occur during the rainy seasonsJune-November. Acquired immunity may be temporary but usually permanent. Signs and Symptoms An acute febrile infection of sudden onset with clinical manifestation of 3 stages: First 4 daysFebrile or invasive stage starts abruptly as high fever, abdominal pain and headache; later flushing which may be accompanied by vomiting, conjunctival infection and epistaxis. Petechiae may be observed in pressure areas usually first on the face or distal portions of the extremities. 4th-7th daysToxic or hemorrhagic stagelowering of temperature, severe abdominal pain, vomiting and frequent bleeding from gastrointestinal tract in the form of hematesis or melena. Unstable BP, narrow pulse pressure and shock may occur. Tourniquet test which may be negative due to low or vasomotor collapse. 7th-10th daysconvalescent or recovery stage generalized flushing with intervening areas of blanching appetite regained and blood pressure already stable. Grading of Dengue Fever The severity of DHF is categorized into four grades: Grade I, fever without overt bleeding but with positive tourniquet test Grade II, manifestation of Grade I with clinical bleeding diathesis such as epistaxis, gum bleeding, GI bleeding and hematemesis

 Grade III, circulatory failure manifested by a rapid and weak pulse with narrowing pulse pressure (20 mmHg) or hypotension, with the presence of cold clammy skin and restlessness; and Grade IV, profound shock in which pulse and blood pressure are not detectable. It is noteworthy that patients who are in threatened shock or shock stage, also known as dengue shock syndrome, usually remain conscious. Grade III and IV are considered to be Dengue Shock Syndrome

Laboratory and Diagnostic Tests 1.) Tourniquet Test (Rumpel Leads Tests) Inflate the blood pressure cuff on the upper arm to a point midway between the systolic and diastolic pressure for 5 minutes Release cuff and make an imaginary 2.5 cm square or 1 inch just below the cuff, at the antecubital fossa Count the number of petechiae inside the box A test is (+) when 20 or more petechiae per2.5 cm square or 1 inch square is observed. 2.) A confirmed diagnosis is established by culture of the virus, polymerase chain reaction (PCR) tests, or serologic assays. The diagnosis of dengue hemorrhagic fever is made on the basis of the following triad of symptoms and signs: Hemorrhagic manifestations; a platelet count of less than 100, 000 per cubic millimeter (thromobocytopenia); and objective evidence of plasma leakage, shown either by fluctuation of packed cell volume (greater than 20 percent during the course of the illness) or by clinical signs of plasma leakage, such as pleural effusion, ascites or hypoproteinemia. Hemorrhagic manifestations without capillary leakage do not constitute dengue hemorrhagic fever. Management Supportive and symptomatic treatment should be provided:

 Promote rest Medication There are no specific antivial drugs. Paracetamol for fever Analgesic (Acetaminophen (Tylenol) and codeine) for severe headache and joint and muscle pains Aspirin and nonsteroidal antiinflammatory drugs should be avoided o Rapid replacement of body fluids is the most important treatment

Give ORESOL to replace fluid as in moderate dehydration at 75ml/kg in 46 hours or up to 23L in adults. Continue ORS intake until paients condition improves. Intravenous fluid o For hemorrhage

Keep patient at rest during bleeding periods For epistaxis maintain an elevated position of trunk and promote vasoconstriction in nasal mucosa membrane through an ice bag over the forehead. For melena ice bag over the abdomen. Provide support during the transfusion therapy o Diet

Low fat, low fiber, nonirritating, noncarbonated Noodle soup may be given o o Observe signs of deterioration (shock) such as low pulse, cold clammy perspiration, prostration. For shock

Place in dorsal recumbent position to facilitate circulation Provision of warmth through lightweight covers (overheating causesvasodilatation which aggravates bleeding) Prevention The best way to prevent dengue fever is to take special precautions to avoid contact with mosquitoes.

 Eliminate vector by: Changing water and scrubbing sides of lower vases once a week Destroy breeding places of mosquito by cleaning surroundings Proper disposal of rubber tires, empty bottles and cans Keep water containers covered because Aedes mosquitoes usually bite during the day, be sure to use precautions especially during early morning hours before daybreak and in the late afternoon before dark. Other precautions include: When outdoors in an area where dengue fever has been found Use a mosquito repellant containing DEET, picaridin, or oil of lemon eucalyptus Dress in protective clothing long sleeved shirts, long pants, socks, and shoes Keeping unscreened windows and doors closed

OBJECTIVES
NURSE-CENTERED OBJECTIVES General Objective To be knowledgeable about the nature of Dengue Hemorrhagic Fever, management and treatment to be able to render effective nursing care to the client. Specific Objectives

Upon the completion of this case study, the student-nurses shall have:

Understood the accurate information about the clients past history and illness in relation to clients condition Exhibited the anatomy and physiology of the body system involved in the disease.

Acquired knowledge about the specific medications of the patient as well as its action, indication, contraindications and adverse reaction.

Utilized all the nursing interventions in abiding to the nursing process. Expounded on the laboratory and diagnostic procedures done with the patient, their purposes, and specific nursing responsibilities before, during and after the procedure.

And

integrated

the

appropriate

health

teachings

for

proper

home

management of the health problem and promotion of self care.

NURSING
BIOGRAPHIC DATA:

HEALTH

HISTORY

Client X is a 14 year old female who is currently residing at 17th St. Luzviminda Kenneth Road, Nagpayong Pinagbuhatan, Pasig City. She was born on September 1, 1996. She was the only child of her parents. She is a Roman Catholic. She is a second year student in Nagpayong High School. CHIEF COMPLAINT: pabalik balik yung lagnat ko, as verbalized by the client. HEALTH HISTORY:

A. History of Present Illness

Three days prior to admission, the client had fever, headache and abdominal pain. Before she had fever, she came from school for their practice. After three days, they went to Bro. Francisco Perez Clinic in Taytay, Rizal for check-up because of abdominal pain. Her blood test results revealed decrease number of platelets (80g/L) and WBC (2.5g/L). she was diagnosed there having dengue fever syndrome and was refer to any hospital with request for Complete Blood Count with Platelet Count, Urinalysis and ordered to take paracetamol by lunch. Then they went to the emergency room of Pasig City General Hospital. On the day of admission, the client was ambulatory, had stable vital signs, had weight of 28.3 kg and with flushed skin. B.Past History The client already had mumps and chicken pox during childhood. She had complete immunizations, as verbalized by her mother. She already had fever, cough and colds. She doesnt have any food, drug or environmental allergy. As stated by the client, she doesnt experience any accidents in the past and this is the first time she was confined into a hospital. C. Family History The client is the only child in the family. Her father is already 43 years old and currently working as a painter, carpenter, or as a construction worker depending on the available job. While her mother, age 42, is a plain house wife taking care of household chores. Her mother has hypertension. Her mother also added that they dont have a history of Tuberculosis, Diabetes, Heart Disease and Cancer. FUNCTIONAL HEALTH PATTERNS 1. Health Perception and Health Management Pattern The client stated that her general health is good for she seldom get sick. She doesnt have regular exercise except or the activities in school and the morning exercise during flag ceremonies on Monday. No cough and colds was noted 3 weeks PTA. She is not drinking liquor nor smoking cigarettes ever since. It was her first time to be admitted in the hospital. The client said that she may have acquired her illness from school since there were reported cases of dengue at their school few days before she was admitted. The important thing she keeps on her mind

while she is in the hospital is that she needs to follow orders from the doctors and nurses to be well so that she can go to school. Her mother thinks that we can help them by answering their question whenever something is not clear to them and also by monitoring her daughters vital signs. Whenever someone is sick in the family, they immediately consult their barangay health center and also seek what they called albularyo. They believe in tawas and hilot but health center is where they always consult first. 2. Nutrition and Metabolic Pattern BEFORE ADMISSION The client usually eat any available kind of food (fish, meat, vegetables, fruits) but most especially viands with soup for three meals per day; around 6:00 in the morning, her breakfast comprises of a cup of fried rice with a fried fish or egg. During morning snacks, she used to eat sandwich or any viand available at school. During lunch time, her mother prepares a meal comprises of dishes like nilagang baka. She consumes 12 cups of rice on the said meal. She used to eat bread or during merienda time. During dinner, he usually eats sinigang na baboy. She drinks 6-8 glasses of water a day, approximately 2000 ml of water (1 cup= 250ml). She doesnt drink soda because shes afraid her father might scold her. Shes is also not fond of eating junk foods and sweets. She used to take supplements and vitamins. Theres no change in her appetite and theres no discomfort during eating or drinking. The client doesnt have any dentures. She also said that there is no food that she is allergic to. DURING CONFINEMENT The client stated that in the hospital, she doesnt eat a lot but any food available will do. According to her his appetite slightly decreased because of her not-so-good condition. She consumes three meals a day. Her meal usually comprises of food with soup and she drinks 6-8 glasses of water a day, approximately 2000 ml of water (1 cup= 250 ml). She increases her water intake as ordered by the doctor and nurse.

3. Elimination Pattern BEFORE ADMISSION The clients bowel elimination pattern is once a day-every afternoon. The color of his stool is from yellow to brown. She also said that she have no difficulty

in defecation. With regards to her urine elimination pattern, she stated that she urinates about 4x a day. The color of her urine is yellowish one. She doesnt have any difficulty in urination and doesnt have excess perspiration. DURING CONFINEMENT The clients bowel elimination and urine elimination does change a little. She urinates more than 5x a day. The color of the urine is a yellowish one. He defecates once a day at different times of times of the day. The color of her stool is not dark and it is formed in shape. He has excess perspiration and odor problems. 4. Activity and Exercise Pattern BEFORE ADMISSION The client said that she has a sufficient energy for completing desired required activities at school and at home. She has no regular exercise except for the activities at school and the morning exercise during Monday flag ceremonies During her spare time, she used to watch TV but only for about an hour because most of her time is allocated for doing her assignments and projects. DURING CONFINEMENT Due to the clients condition, she has little energy for completing desired required activities. She cant do all things that she usually do when she was admitted in the hospital.

1st DAY INTERVIEW ( November 15, 2010) She has perceived ability for: Feeding 0 and sometimes 2 Grooming 0 General Mobility 0 Toileting - 0 Cooking N/A Home maintenance N/A Dressing 2 because of her IV infusion Shopping N/A NOTE: Level 0: Full Self Care Level 1: Requires use of equipment or device Level 2: Requires assistance or supervisions from another person Level 3: Requires assistance or supervision from another person/or device Level 4: Is dependent and does not participate N/A: Not Applicable

5. Sleep Rest Pattern BEFORE ADMISSION The client stated that she has a continuous sleep, which comprises of 5-7 hrs of sleep. Shes not taking any nap during afternoon because of school assignments. She usually sleeps on a side lying position. Shes not taking any sleeping pills. She also added that she dont feel any tiredness upon waking up. DURING CONFINEMENT Now that the client is in the hospital, her sleep is always interrupted due to frequent monitoring of Vital Signs. Her sleep is also interrupted due to the environment in the hospital. But sometimes she sleeps for about 4-8 hours. She sleeps in a supine position. Client perceives that the quality of sleep was the most important rather than the quantity of sleep. 6. Cognitive Perceptual Pattern The client verbalized that shes have no hearing difficulty in both ears and so she is not using hearing aids. She also stated that she doesnt wear any eyeglasses ever since. She doesnt have any history of check- up in any ophthalmologist. His pupils are equally rounded and reactive to light and accommodation. The client verbalized that she doesnt have difficulty in reading small writings. There are no changes in her memory lately, upon assessment it was found out that the client is oriented to time and place. The easiest way for the client to learn things are through reading. He doesnt have any difficulty in learning new things. 7. Self Perception and Self Concept Pattern The client describes herself as a simple girl living a simple life. Shes a happy person and not irritable. Before the illness started, there is no hindrance for her to do any activity except that shes really not into sports coz of her slim body. She doesnt mind those few people who make her angry. She used to just ignore them and just continue with her own life. The thing that makes her cry is when she cant go to school or cant pay school fees because shes afraid that her teacher might scold her. She easily cries when she cant do her projects related to financial matters. Despite of her condition now she still has positive attitudes about herself. 8. Role-Relationship Pattern

The client belongs to a nuclear family. She is living with her mother and father. She doesnt have problems that are difficult to handle. Her family does depends on her father especially on financial aspects. Everytime she has problems, she immediately consult her mother because most of the time, her father is at work. Every time their family encounters a problem, they talk about it at once for them not to prolong their problem. The most common problem that they encounter is financial. Her support system in time of stress is her friends and family especially her mother. Whenever her father can support their financial needs just like during her hospitalization, they seek help from their other relatives. She doesnt feel alone frequently; in fact she is a cheerful person. 9. Sexually-Reproductive Pattern The client is already in the latency stage based on Freuds Psychosexual stages of development wherein in sexual urges sublimated in to sports and hobbies. She is fond of drawing but not into sports. She is not active in sexual intercourse. She already had her first menstruation when she was 13 years old. According to Ericksons Psychosexual stages of development, he client is in the stage of identity versus role confusion wherein its the time for her to develop an identity, and decide for her career goals. According to her mother, she is really fond of drawing and very eager to study and finishes her tasks ahead of time. 10. Coping Stress Tolerance Pattern The term coping refers to the strategies a person utilize to adapt to physiological and psychological problem or change. Upon assessment, she feels comfortable and not stress. Things that stress her are more of the school projects that cause her to sleep late at night sometimes. The client explained that whenever something bothers her, she easily talks to her mother about it and so in that way, stress is avoided since her mother is always there to help her. 11. Value-Belief Pattern The clients mother verbalized that her daughter is very religious. The client goes to church every Sunday. And if her mother cant come with her to church, she goes with her Aunt and doesnt want to skip mass on Sundays. She says a prayer every night before she goes to sleep. She knows that he cant have everything that she wanted and accepted that but when it comes to school fees, she really wanted

to afford those to avoid being scold. The most important thing in his life now is her family, health and studies. On a scale of 1-10; 10 being the highest she chose 10. Thats how much important her family is. She stated that her religious beliefs and practices dont interfere with her hospitalization. But being hospitalized interfere with her religious practices since she cant go to mass when Sunday.

PHYSICAL EXAMINATION
PARTS
LOC Appearance Development Nutritional status Emotional state Gait Color Texture Turgor Temperature Moisture Others Configuration Hair Scalp Face Lids Conjunctiva Sclera Cornea & Lens Pupil Size Visual acuity External Pinnae External Canal Gross Hearing INSPECTION

METHOD USED

FINDINGS
Alert, coherence, oriented No signs of distress Ectomorph Cachexic Calm Coordinated Flushed Smooth Fair Warm Moist, slightly oily No lesions, some petechial rash on legs. Normocephalic Evenly distributed Presence of dandruff Symmetry Symmetrical Pinkish, no discharge Anicteric Smooth, clear Equal Normal, do not wear eye glasses. Symmetrical, no tenderness No discharge symmetrical

INTERPRETATI ON

GENERAL

INSPECTION

NORMAL

SKIN

INSPECTION

NORMAL

HEAD

INSPECTION

NORMAL

EYES

INSPECTION

NORMAL

EARS

NORMAL

EYES SINUSESNOSE &

Mucosa Patency Gross smell Sinuses

INSPECTION & PALPATION

Pinkish, no discharge Both are patent Symmetrical nontender Slightly dry Pinkish, midline Caries, 3 missing teeth Pinkish, non tenderness Pinkish Intact Deviation to the R Non inflamed

NORMAL

PHARYNXMOUTH &

Lips Tongue Teeth Gums Mucosa Speech Uvula Tonsils

INSPECTION & PALPATION

NORMAL

Trachea Lymph nodes Thyroids

INSPECTION & PALPATION

Midline Nonpalpable Nonpalpable

NECK

NORMAL

ABDOMEN LUNGSTHORAX & BREAST

PATIENT REFUSED

Breathing pattern Shape of chest Percussion Breath sounds

AUSCULTATION INSPECTION PALPATION PERCUSSION

Eupnea AP ratio 1:2 Resonant Vesicular

NORMAL

Skin Umbilicus Configuration Bowel sounds Percussion

INSPECTION AUSCULTATION PERCUSSION PALPATION

Same with the skin color Sunken Flat Slightly hyperactive Tympanic

NORMAL

EXTREMITIESUPPER / LOWER RECTALGENITAL &

PATIENT REFUSED

Size Skin color Lesions Temperature Others:

INSPECTION AND PALPATION

Equal size Light to deep No lesions Warm Symmetry with visible veins; fingers, arm, shoulder and wrist can move freely in different direction; mark of some petechial rash

NORMAL

THEORETRICAL

FRAMEWORK

The group used the following 4 nursing theories to achieve their aim health-promoting behavior of the patient: (1) Lydia Halls Core, Care and Cure Model, (2) Hildegard Peplaus Interpersonal Relationship Theory, (3) Florence Nightingales Environmental Theory and (4) Imogene Kings Goal Attainment Theory.

The theories of Lydia Hall, Hildegard Peplau, Florence Nightingale and Imogene King are combined to each other because of their intense interrelationship. Hildegard Peplaus Interpersonal Relationship Theory is the backbone of Figure 1, for it illustrates the interpersonal communication between the patient and healthcare team which affects the healthcare decision-making and delivery. We may say that Lydia Halls Core, Care and Cure Model & Imogene Kings Goal Attainment Theory and Florence Nightingales Environmental Theory, Imogene Kings Goal Attainment Theory and Care part of Core, Care and Cure Model happen simultaneously. Environmental Theory is centered at the Care part of Lydia Halls Core, Care and Cure Model. But, it is affected by Imogene King and Hildegard Peplau. Nightingale states 5 components of environment that the nurse should modify to satisfy the Care part of Halls theory. Modification of the environment should be facilitated by the nurse because this is an independent nursing intervention. While, Core, Care and Cure Model and Goal Attainment Theory illustrate the implementation of different specific needed interventions by the patient, nurse and doctors or other health care team members through their continuous reaction and interaction. The Transaction phase of Goal Attainment Theory signifies the evaluation of nursing process. It shows if the goal is met or not which is health-promoting behavior. Therefore, ongoing assessment will be very essential to adjust interventions when necessary.

ANATOMY & PHYSIOLOGY

THE SYSTEMIC CIRCULATION

Major ARTERIES (in bright red) and VEINS (dark red) of the system
Blood from the aorta passes into a branching system of arteries that lead to all parts of the body. It then flows into a system of capillaries where its exchange functions take place. Function only: to supply materials to and remove materials from the capillaries. Blood from the capillaries flows into venules which are drained by veins. o Veins draining the upper portion of the body lead to the superior vena cava. o Veins draining the lower part of the body lead to the inferior vena cava. o Both empty into the right atrium.

BLOOD
Blood is a liquid tissue. Suspended in the watery plasma are seven types of cells and cell fragments. red blood cells (RBCs) or erythrocytes platelets or thrombocytes kinds of white blood cells (WBCs) or leukocytes Three kinds of granulocytes Neutrophils eosinophils basophils Two kinds of leukocytes without granules in their cytoplasm lymphocytes monocytes

FUNCTIONS OF THE BLOOD

Blood performs two major functions: transport through the body of oxygen and carbon dioxide food molecules (glucose, lipids, amino acids) ions (e.g., Na+, Ca2+, HCO3) wastes (e.g., urea) hormones heat Defense of the body against infections and other foreign materials. All the WBCs participate in these defenses

TYPES OF BLOOD CELLS

Are produced in the bone marrow (some 1011 of them each day in an adult human!). Arise from a single type of cell called a multipotent stem cell.

STEM CELLS
are very rare (only about one in 10,000 bone marrow cells); are attached (probably by adherens junctions) to osteoblasts lining the inner surface of bone cavities; produce, by mitosis, two kinds of progeny: More stem cells (A mouse that has had all its blood stem cells killed by a lethal dose of radiation can be saved by the injection of a singleliving stem cell!). Cells that begin to differentiate along the paths leading to the various kinds of blood cells.

PATHOPHYSIOLOGY
Precipitating Factors: Previous dengue infection Environmental condition Mosquito carrying a different strain

Predisposing Factors: Age 32y/o

Aedes aegypti (dengue virus carrier): 8-12 days of viral replication on mosquitos salivary glands Bite from mosquito (Portal of Entry in the Skin) Inoculation of dengue virus in the circulation/blood (Incubation Period: 3-14 days) Rapid dissemination of dengue virus in the blood Inflammatory Response Redness; itchiness in the area

Macrophages & monocytes

Immunoglobulins (Specific antibodies of previous virus strain) Attachment to the dengue virus to facilitate phagocytosis

Phagocytize the dengue virus through the Fc receptor (FcR)

Unable to deactivate the virus

Virus Replication takes place Multiplies & Release to the blood stream

Decreased WBC

Fever, body weakness, diaphoresis, headache, warm skin.

Systemic Infection Dengue Fever

NURSING

CARE

PLAN

DRUG

STUDY

PARACETAMOL (Biogesic) 325mg/Tab for FEVER (temp. 37.8 0C)

Brand Name Classification Action Indications Contraindicati ons Acetaminophen, ANALGESIC Decreases fever by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by hypothalamic action leading to sweating & vasodilations. Relief of mild-moderate pain; treatment of fever. Hypersensitivity, intolerance to tartrazine, alcohol, table sugar and saccharin. CNS: Headache CV: Chest pain, dyspnea, myocardial damage when doses of 58 g/day are ingested daily for several weeks or when doses of 4 g/day are ingested for 1 yr GI: Hepatic toxicity and failure, jaundice GU: Acute kidney failure, renal tubular necrosis Hematologic: Methemoglobinemiacyanosis; hemolytic anemia hematuria, anuria; neutropenia, leukopenia, pancytopenia, thrombocytopenia, hypoglycemia Hypersensitivity: Rash, fever Toxicity may be increased in patients receiving other potentially hepatoxic drugs that induce liver microsomal enzymes. The absorption on paracetamol may be accelerated by drugs such as metoclopramide. Do not exceed the recommended dosage. Consult physician if needed for children < 3 yr; if needed for longer than 10 days; if continued fever, severe or recurrent pain occurs (possible serious illness). Avoid using multiple preparations containing acetaminophen. Carefully check all OTC products. Give drug with food if GI upset occurs. Discontinue drug if hypersensitivity reactions occur. Treatment of overdose: Monitor serum levels regularly, -acetylcysteine should be available as a specific antidote; basic life support measures may be necessary. Teaching Point: Do not take for longer than 10 days. Take the drug only for complaints indicated; it is not an antiinflammatory agent. Avoid the use of other over-the-counter preparations. They may contain acetaminophen, and serious overdosage can occur. If you need an overthe-counter preparation, consult your health care provider. Report rash, unusual bleeding or bruising, yellowing of skin or eyes, changes in voiding patterns.

Adverse Effects

Drug Interaction

Nursing Considerations

RANITIDINE 30mg IV every 8 hours

Name Classification Action Indications Contraindicati ons

Zantac, Ramadine
Gastrointestinal Drugs

Inhibits histamine at H2 receptor site in the gastric parietal cells, which inhibits gastric acid secretions. Use in management of various GI disorders such as dyspepsia, GERD, peptic ulcer. Hypersensitivity. History of acute porphyria. Long-term therapy. CNS: Headache, malaise, dizziness, somnolence, insomnia, vertigo CV: Tachycardia, bradycardia, PVCs (rapid IV administration) Dermatologic: Rash, alopecia GI: Constipation, diarrhea, nausea, vomiting, abdominal pain, hepatitis, increased ALT levels GU: Gynecomastia, impotence or decreased libido Hematologic: Leukopenia, granulocytopenia, thrombocytopenia, pancytopenia Local: Pain at IM site, local burning or itching at IV site Other: Arthralgias It can increased effects of warfarin, TCAs, Decreased effectiveness of diazepam, Decreased clearance and possible increased, toxicity of lidocaine, nifedipine Observed the 10 RIGHTs in drug administration. Assess potential for interaction of other pharmacological agents patient may be taking. Assess the knowledge/teach patient about the possible side effects, appropriate intervention and adverse symptoms to report.

Adverse Effects

Drug Interaction

Nursing Consideration s

Monitor AST, ALT, serum creatinine when used to prevent stress-related GI bleeding. Inform the patient that it will take several days before noticeable relief. Allow 1 hr between any other antacids & ranitidine. Follow diet as recommended.

If you miss a dose, use it as soon as you remember. If it is near the time
of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.

TERBUTALINE 2.5mg/tab 2x a day

Name
Bricanyl , Brethine

Classification Action

Respiratory drugs

Specific beta 2 adrenergic receptor stimulant, resulting to bronchodilation and relaxation of peripheral vasculature. It also causes relaxation of uterine smooth muscles and has minimal beta 1 activity. Terbutaline is given as the sulfate for its bronchodilating properties in reversible airways obstruction. It also decreases uterine contractility and may be used to arrest premature labour. Hypersensitivity to sympathomimetic agents. Thyrotoxicosis; pregnancy 1st trimester. Cardiac arrhythmias associated with tachycardia. Palpitation, tachycardia, chest discomfort, arrhythmias, hypertension, CNS stimulation, tremor, dizziness, headache, weakness, nausea, vomiting, GI distress, hypokalemia(high doses), dyspnea, sweating, muscle cramps, ECG changes, increased heart rate, seizures. Beta-blockers, monoamine oxidase inhibitors, tricyclic antidepressants.
Combining terbutaline with thioridazine (Mellaril) may increase the occurrence of abnormal heart rhythms because both drugs can cause abnormal heart rhythms.

Indications Contraindicati ons Adverse Effects Drug Interaction

Nursing Consideration s

Assess patients condition before the therapy and regularly monitor drug effectiveness. Assess respiration (rate, rhythm and character). Monitor and report evidence of allergic reactions, rash, pruritus and urticaria. Monitor for possible drug induced adverse reactions: CNS: nervousness, headache, drowsiness, dizziness, weakness CV: palpitations, tachycardia, arrhythmia, flushing GI: vomiting, nausea, heartburn METABOLIC: hypokalemia, RESPI: paradoxical bronchospasm, dyspnea SKIN: diaphoresis. Assess patients knowledge on drug therapy. Tech patient to monitor for and report adverse reaction.

L-CARNITINE 330mg/tab 2x a day

Brand Name Classification Action
Carnitor Amino acid supplement It is needed to release energy from fat. It transports fatty acids into mitochondria, the powerhouses of cells. For the acute and chronic treatment of patients with an inborn error of metabolism which results in secondary carnitine deficiency. For the prevention and treatment of carnitine deficiency in patients with end stage renal disease who are undergoing dialysis. Used therapeutically to stimulate gastric and pancreatic secretions and in the treatment of hyperlipoproteinemias. None known. The safety and efficacy of oral levocarnitine has not been evaluated in patients with renal insufficiency, pregnant and nursing mothers. Side effects includes abdominal pain, back pain, headache, hypertension, tachycardia, anorexia, diarrhea, dyspepsia, nausea, vomiting, dizziness, weight decrease, paresthesia, pharyngitis, dyspnea, rhinitis. L-carnitine has not been consistently linked with any toxicity.

Indications

Contraindicati ons Adverse Effects

Drug Interaction

The body needs lysine, methionine, vitamin C, iron, niacin, and vitamin B6 to produce carnitine. Phenobarbitals resulted in reduced blood levels of L-carnitine.

Nursing Consideration s

IVF SOLUTIONS
TYPE OF SOLUTION
D5LR 510cc x 6 hours

DATE /TIME
11-30-10 to 12-03-10

INDICATION
Resembles blood serum and rehydration Replace ECF, water overload, medication diluents & compatible with blood. Provides water and electrolytes for maintenance of daily fluid and electrolyte requirements, plus minimal carbohydrate calories.

PNSS 1L x KVO

12-02-10

D5NM 550cc x 8 hours

12-03-10

LABORATORY
HEMATOLOGY
TEST
Neutrocyte Lymphocyte WBC Hemoglobin Hematocrit Platelet count

STUDY
Date : 11/30/10

INDICATION

NORMAL VALUE 0.35-0.65% 0.20-0.40% 4.50-11.00 x 10 g/L 115-160g/L 0.40-0.50g/L 150-400 x 10g/L

RESULT 0.43% 0.37% 2.5/l 158g/l 0.47g/l 80g/l

INTERPRETATION

To identify acute and chronic illness, bleeding tendencies, and white blood cell disorders

Normal
Normal Low

Normal Normal
Decreased; possible immune disorder

HEMATOLOGY
TEST Hemoglobin Hematocrit Platelet count INDICATION To identify acute and chronic illness, bleeding tendencies, and white blood cell disorders NORMAL VALUE 115-160g/L 0.40-0.50g/L 150-400 x 10g/L RESULT 165/l 0.46/l 337/l

Date : 11/30/10
INTERPRETATION Increased possible for Polycythemia, dehydration Normal Normal

HEMATOLOGY
TEST WBC Hemoglobin Hematocrit Platelet count INDICATION To identify acute and chronic illness, bleeding tendencies, and white blood cell disorders NORMAL VALUE 4.50-11.00 x 10 g/L 115-160g/L 0.40-0.50g/L 150-400 x 10g/L RESULT 5.7g/l 169g/l 0.53/l 30g/l

Date : 12/01/10 (11:54am)

INTERPRETATION Normal Increased possible for Polycythemia, dehydration Increased possible for polycythemia, hemoconcentration. Decreased; possible immune disorder

HEMATOLOGY
TEST INDICATION To identify acute and chronic illness, bleeding tendencies, and white blood cell disorders NORMAL VALUE RESULT

Date : 12/01/10 ( 9:53 pm)

INTERPRETATION

Platelet count

150-400 x 10g/L

40g/l

Decreased; possible immune disorder

HEMATOLOGY
TEST INDICATION To identify acute and chronic illness, bleeding tendencies, and white blood cell disorders NORMAL VALUE RESULT

Date : 12/02/10 (1:44 pm)

INTERPRETATION

Platelet count

150-400 x 10g/L

88g/l

Decreased; possible immune disorder

HEMATOLOGY
TEST INDICATION To identify acute and chronic illness, bleeding tendencies, and white blood cell disorders NORMAL VALUE RESULT

Date : 12/03/10 (3:06 pm)

INTERPRETATION

Platelet count

150-400 x 10g/L

85g/l

Decreased; possible immune disorder

HEMATOLOGY
TEST INDICATION To identify acute and chronic illness, bleeding tendencies, and white blood cell disorders NORMAL VALUE RESULT

Date : 12/04/10 (11:18am)

INTERPRETATION

Platelet count

150-400 x 10g/L

99g/l

Decreased; possible immune disorder

BLOOD CHEMISTRY (Cardiac Enzymes & Proteins)

TEST CK-MB LDH INDICATION Specific indication for the diagnosis of myocardial infarction. NORMAL VALUE 313. 618. 0. 16. RESULT 995. 24.

Date : 12/04/10 (10:01am)

INTERPRETATION High (possible MI) High (Possible for Acute MI)

BLOOD CHEMISTRY (Cardiac Enzymes & Proteins)

TEST CK-MB LDH INDICATION Specific indication for the diagnosis of myocardial infarction. NORMAL VALUE 313. 618. 0. 16. RESULT 1107. 17.

Date : 12/04/10 (10:01am)

INTERPRETATION High (possible MI) Slightly Elevated

DISCHARGE
M- Medication

PLAN

Continue taking prescribe medication for the patient on exact dosage, time, and frequency making sure that the purpose of the medication is truly discussed by the health care provider.

Instruct the patient to follow the instruction when administering meds. Advice the patient not to stop intake of prescribed meds, unless approved by the physician. Dont give aspirin and NSAIDs; they increase the risk of bleeding. Any medicines that decrease platelet count should be avoided.

E- Exercise Instruct to avoid excessive activities that may result to stress. Just advised to perform range of motions and repetitive body movements for promotion of optimum health. Remind about the need for health promotion activities such as reading, watching T.V, etc T Treatment Bed rest is advisable during the re-occurrence of fever phase. Instruct to drink plenty of water or fluids that are available at home and eat nutritious diet. Advised to look for re-occurrence of danger signs and symptoms and report immediately. H Hygiene Encourage to continue the routinely hygienic care of the patient O OPD Instruct the family members to have a check-up or to consult physician once a while to monitor patients condition and for detection of recurrences and other complications that may arise on to it. D Diet Instruct the family members to give the client protein rich foods such as meat, fish, eggs and dairy products.