INTRODUCTION

Dengue is basically characterized as a community-based disease requiring the interplay between man, the viral agent that causes the disease and the mosquito vector. A more serious but less common form of the disease, Dengue Hemorrhagic Fever (DHF), may cause severe and fatal internal bleeding. Dengue Fever and Dengue Hemorrhagic Fever are caused by any of four different viruses and are transmitted directly to another by the female mosquito of two species of the genus Aedes. The infection cannot be transmitted directly from person to person and not all people who are bitten necessarily contract the disease.

Based on latest disease surveillance report of DOH, Center for Health and DevelopmentCaraga Regional Epidemiology and Surveillance unit, Dengue case decreased to 70% compared last year 1,303 cases of the said disease. According to Dr. Gerna Manata, Regional Epidemiologist, there are 397 cases of Dengue recorded in the month of January to June 11, 2011 in Caraga. Surigao City took the first place of having a large number of dengue cases entire Caraga with 83 cases recorded. We were given the opportunity to have a hospital exposure last July 26-27, 2011 at Caraga Regional Hospital- Pedia ward; and on the said date found a commendable case reasonable to be presented for case study. Our case is all about a 7 years old male child who is currently residing at Purok 3 Brgy.San Juan, Surigao City, Surigao Del Norte. Mr. CL was admitted at Caraga Regional Hospital last July 22, 2011 with chief complaints of fever and cough for 3 days with chest pain and with a final diagnosis of Dengue Hemorrhagic Fever Grade II. The objective of this study is to help us understand the disease process of Dengue Hemorrhagic Fever and to orient ourselves for appropriate nursing interventions that we could offer to the patient. This approach enables us to exercise our duties as student nurse which is to render care. We had given the chance to improve the quality of care we can offer and to pursue our chosen profession as future nurse.

We humbly present our studied case and submit ourselves for further corrections to widen the scope of our knowledge and understanding.

REVIEW OF RELATED LITERATURE

What is dengue fever and dengue hemorrhagic fever? Dengue fever is a flu-like illness spread by the bite of an infected mosquito. Dengue hemorrhagic fever is a severe, potentially deadly infection spread by certain species of mosquitoes (Aedes aegypti). Alternative names: Hemorrhagic dengue; Dengue shock syndrome; Philippine hemorrhagic fever; Thai hemorrhagic fever; Singapore hemorrhagic fever. What is the infectious agent that causes dengue? Dengue and dengue hemorrhagic fever are caused by any of the dengue family of viruses. Infection with one virus does not protect a person against infection with another. How is dengue spread? Dengue is spread by the bite of an Aedes mosquito. The mosquito transmits the disease by biting an infected person and then biting someone else. Where is dengue found? Dengue viruses occur in most tropical areas of the world. Dengue is common in Africa, Asia, the Pacific, Australia, and the Americas. It is widespread in the Caribbean basin. Dengue is most common in cities but can be found in rural areas. It is rarely found in mountainous areas above 4,000 feet. The mosquitoes that transmit dengue live among humans and breed in discarded tires, flower pots, old oil drums, and water storage containers close to human dwellings. Unlike the mosquitoes that cause malaria, dengue mosquitoes bite during the day. What are the signs and symptoms of dengue fever and dengue hemorrhagic fever? Dengue fever begins with a sudden high fever often as high as 104 - 105 degrees Fahrenheit. A flat, red rash may appear over most of the body 2 - 5 days after the fever starts. A second rash, which looks like the measles, appears later in the disease. Infected people may have increased skin sensitivity and are very uncomfortable. Other symptoms include: Headache (especially behind the eyes) Fatigue joint aches Muscle aches Nausea Swollen lymph nodes 2

Vomiting

Early symptoms of dengue hemorrhagic fever are similar to those of dengue fever, but after several days, the patient becomes irritable, restless, and sweaty. These symptoms are followed by a shock-like state. Bleeding may appear as tiny spots of blood on the skin (petechiae) and larger patches of blood under the skin (ecchymoses). Minor injuries may cause bleeding. Shock may cause death. If the patient survives, recovery begins after a one-day crisis period. Early symptoms include: o Decreased appetite o Fever o Headache o Joint aches o Malaise o Muscle aches o Vomiting Acute phase symptoms include: Restlessness followed by: o Ecchymosis o Generalized rash o Petechiae o Worsening of earlier symptoms Shock-like state o Cold, clammy extremities o Sweatiness (diaphoretic) Signs; A physical examination may reveal: o Enlarged liver (hepatomegaly) o Low blood pressure o Rash o Red eyes o Red throat o Swollen glands o Weak, rapid pulse Stages of Dengue Hemorrhagic Fever * Grade I: fever + Herman's sign (flushes and redness of skin with lighter color at the center of the rash) * Grade II: Grade I symptoms + bleeding (epistaxis or nose bleeding, gingival bleeding, hematemesis or upper gastrointestinal bleeding; e.g: vomiting of blood), and melena or dark stool. * Grade III: Grade II + Circulatory Collapse (hypotension, cold clammy skin and weak pulse) * Grade IV: Grade III + Shock.

Complications of Dengue Hemorrhagic Fever Encephalopathy Liver damage Residual brain damage Seizures Shock How soon after exposure do symptoms appear? The time between the bite of a mosquito carrying dengue virus and the start of symptoms averages 4 to 6 days, with a range of 3 to 14 days. An infected person cannot spread the infection to other persons but can be a source of dengue virus for mosquitoes for about 6 days. How is dengue diagnosed? Dengue is diagnosed by Tests may include: Arterial blood gases Coagulation studies Electrolytes Hematocrit Liver enzymes Platelet count Serologic studies (demonstrate antibodies to Dengue viruses) Serum studies from samples taken during acute illness and convalescence (increase in titer to Dengue antigen) Tourniquet test (causes Petechiae to form below the tourniquet) X-ray of the chest (may demonstrate pleural effusion)

Who is at risk for dengue hemorrhagic fever? Factors that put you at greater risk of developing dengue fever or a more severe form of the disease include:

Living or traveling in tropical areas. Being in tropical and subtropical areas around the world especially in high-risk areas, such as tropical Asia, Central and South America, and the Caribbean increases your risk of exposure to the virus that causes dengue fever. Dengue virus transmission occurs year-round, although the risk is highest during a recognized dengue fever outbreak. Prior infection with a dengue fever virus. Previous infection with a dengue fever virus increases your risk of a more severe form of the disease. This is especially true for children. If you've had dengue fever before, you can get it again if you become infected with another one of the four denguecausing viruses. Having antibodies to a virus in your blood from a previous infection usually helps protect you. But in the case of dengue fever, it actually increases your risk of severe disease dengue hemorrhagic fever if you're infected again.

Race
Ethnicity is nonspecific, but the disease's distribution is geographically determined. Fewer cases have been reported in the black population than in other races.

Sex
No predilection is known; however, fewer cases of DHF/DSS have been reported in men than in women.

Age
All ages are susceptible. In endemic areas, a high prevalence of immunity in adults may limit outbreaks to children. What is the treatment for dengue and dengue hemorrhagic fever? There is no specific treatment for dengue. Persons with dengue fever should rest and drink plenty of fluids. They should be kept away from mosquitoes for the protection of others. Because a virus for which there is no known cure or vaccine causes Dengue hemorrhagic fever, 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 How common is dengue? In tropical countries around the world, dengue is one of the most common viral diseases spread to humans by mosquitoes. Tens of millions of cases of dengue fever and up to hundreds of thousands of cases of dengue hemorrhagic fever occur each year.

In the Philippines, Department of Health (DOH) today reported that the number of dengue cases for the first half of the year increased by eight percent compared to the same period last year. The DoH said that it received almost 23,000 cases of dengue from January to May 2011 and with the approaching schoolyear, has declared June as Dengue Awareness Month. Most of the incidents reported came from the National Capital Region, with Quezon City having the highest number with 1,694 followed by Manila with 824, Caloocan with 775, Pasig 592, Valenzuela 466, and Paranaque City with 400 cases, among others. Based on the latest disease surveillance report of Department of Health, Center for Health and Development-Caraga Regional Epidemiology and Surveillance Unit, here are the number of cases of dengue in different cities and provinces in Caraga Region within the month of January to June 11, 2011: (1) Surigao City-83; (2) Butuan City-72; (3) Surigao del Norte -65; (4) Surigao del Sur -57; (5) Agusan del Sur 50; (6) Agusan del Norte 35; (7) Tandag City -13; (8) Cabadbaran City-12; (9) Bislig City-5; (10) Bayugan City -4; and (11) Dinagat Islands -1.

Is dengue an emerging infectious disease? According to D.J. Gubler & G.G. Clark, PubMed Journalists, all types of dengue virus are reemerging worldwide and causing larger and more frequent epidemics, especially in cities in the tropics. The emergence of dengue as a major public health problem has been most dramatic in the western hemisphere. Dengue fever has reached epidemic levels in Central America and is threatening the United States.

Several factors are contributing to the resurgence of dengue hemorrhagic fever: No effective mosquito control efforts are underway in most countries with dengue. Public health systems to detect and control epidemics are deteriorating around the world. Rapid growth of cities in tropical countries has led to overcrowding, urban decay, and substandard sanitation, allowing more mosquitoes to live closer to more people. The increase in non-biodegradable plastic packaging and discarded tires is creating new breeding sites for mosquito. Increased jet air travel is helping people infected with dengue viruses to move easily from city to city. Dengue hemorrhagic fever is also on the rise. Persons who have been infected with one or more forms of dengue virus are at greater risk for the more severe disease. With the increase in all types of virus, the occurrence of dengue hemorrhagic fever becomes more likely. How can dengue be prevented? There is no vaccine to prevent dengue. Prevention centers on avoiding mosquito bites when traveling to areas where dengue occurs and when in U.S. areas, especially along the Texas-Mexico border, where dengue might occur. Eliminating mosquito-breeding sites in these areas is another key prevention measures.

Avoid mosquito bites when traveling in tropical areas. Use mosquito repellents on skin and clothing. When outdoors during times that mosquitoes are biting, wear long-sleeved shirts and long pants tucked into socks. Avoid heavily populated residential areas. When indoors, stay in air-conditioned or screened areas. Use bed nets if sleeping areas are not screened or air-conditioned. If you have symptoms of dengue, report your travel history to your doctor. Eliminate mosquito breeding sites in areas where dengue might occur: Eliminate mosquito breeding sites around homes. Discard items that can collect rain or run-off water, especially old tires. Regularly change the water in outdoor birdbaths and pet and animal water contain.

PATIENT HEALTH HISTORY

. BIOGRAPHIC DATA Name of the Patient: Date of Birth: Age: Sex: Address: Religion: Civil Status: Health care financing and usual source of medical care: Source and reliability of data gathered Primary source of data: Secondary source of data: Date and Time of Clinical encounter: . ADMISSION DATA Name of hospital: Case number: Ward service: Date of admission: Time of admission: Mode of admission: Date of discharge: Time of Discharge: Weight: Height: Vital signs upon admission Temperature: Pulse rate:S Respiration rate: Chief complaint: Admitting diagnosis: Final diagnosis: Admitting physician: Attending physician:

Mr. CL July 7, 2004 7 years old Male Purok 3 Brgy. San Juan, Surigao City Roman Catholic Child Philhealth beneficiary Patient SO Patient Chart July 26-27, 2011

Caraga Regional Hospital 56132 PEDIA WARD- Miscellaneous Room July 22, 2011 03:40 PM Ambulatory July 27, 2011 02:30 PM 20 kilograms
119cm or 39

380C 116 bpm 32 cpm Chest pain, fever and cough for 3 day Dengue Fever Dengue Hemorrhagic Fever: Grade II Dr. Janice T. Patio Dr. Cheryl A. Gotinga

C.HISTORY OF PRESENT ILLNESS Three days Prior to Admission, the patient experienced on and off fever and cough with chest pain. Patient took paracetamol tempra for fever without prescription. On July 21, 2011, patient vomit with blood in scanty amount as the SO noted. On July 22, 2011 the patient still had a fever with body temperature of 37.9C as stated by the mother. At around 3:40pm, this prompted the family to admit the patient at Caraga Regional Hospital.

D.PAST HEALTH HISTORY Childhood Illnesses According to the SO, the patient experienced childhood illness such as cough and fever and chicken pox when he was 4 years old. Childhood Immunization Mr. CL has received one dose of BCG, 3 doses of OPV, 3 doses of DPT, 3 doses of HB and one dose of Measles. History of Hospitalization As stated by the SO, this is his first hospitalization and admission. Medical history The patient has no medical history, as verbalized by the SO. Surgical history According to the SO, he has not yet undergone any surgical operations. Accidents and Injuries According to the SO, he had no known accidents and injuries experienced. Allergies and the Type of Reaction The patient has no known allergies to food or any medication, according to the SO. Medications The patient has no known allergies to food or any medication, according to the SO.

Family Health history According to the patient SO (his mother), they have no heredofamilial disease both side of the family. E.LIFESTYLE Personal Habits Pre-hospitalization: The patient habits are playing at the living room with his siblings, eating, watching television and sleeping, according to the SO. During Hospitalization: The patient has always been on bed most of the time and played his toys. Diet Pre-hospitalization: Mr. CL is a not picky eater; he ate everything being prepared by his mother, he eats 3 meals a day (one piece of fish, 1 cup of rice with cup of vegetables and one piece of banana) and 2 snacks like biscuit during his class in the morning and in the afternoon, according to the SO. During hospitalization: Mr. CL experienced loss of appetite and hasnt eaten a lot, he just want to eat like fried chicken, piattos, nova but with limitation according to the SO. He is on a DAT (Diet as Tolerated) except dark colored food.

Sleep/Rest Patterns: Pre-hospitalization: Patient usually sleeps before 8:00 pm and wake up at 6:00 am were a total of 10 hours slept in a day, according to the SO. During hospitalization: Patient was having difficulty in sleeping because of the condition he felt and had sleep disturbances at night due to vital signs monitoring and to some environmental factors such as noise at the ward and estimated tome 8 hours intermittent, according to the SO.

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Elimination Patterns Pre-hospitalization: Mr. CL urinates 4-6 times per day, and defecates once a day. He has no difficulties in urination and defecation, according to the SO. During hospitalization: Mr. CL urinates 3-4 times per day. He was not able to defecate during our shift of duty at the hospital, according to the SO.

Activities of daily Living (ADLs) Pre-hospitalization: Mr.CL can brush his teeth and eat food without help. With assistance taking a bath, dressing and grooming, according to the SO. During hospitalization: Mr.CL has always been on bed most of the time and played his toys.His activity was limited lying on bed but the patient is given his bathroom Privileges with assistance of SO. F. SOCIAL DATA Family Relationships/Friendships The patients relationship with his parents is very close, in time of his illness his both parents always there for him to care and give attention. Educational History The patient is Grade 1 pupil enrolled in Surigao West Elementary School G.ENVIRONMENTAL DATA According to the SO, their house is made of wood and concrete. It is located in an untidy backyard, uncovered water containers, rubber tires and tin cans not properly placed and there is open canal drainage at the left side of their house. This was considered as a precipitating factor that contributes to the disease process.

H.PSYCHOLOGICAL DATA The patient has no psychological problems, as stated by the SO. The patient said that his both parents are so caring, loving, understanding to him. His parents gave more attention to him and patient is oriented.

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I.GROWTH AND DEVELOPMENT School-age child, from 7 to 12 years old in the psychosocial development of Erik Eriksons the school age are in industry versus inferiority. According to Freud in latency stage his energy focused on learning: gaining new skills and ideas. According to Piagets preoperational stage, the child not only uses symbols representationally, but can manipulate those symbols logically. During this period the child learns to relate events can understand relationships. Our patient achieved all of this. J.PATTERN OF HEALTH CARE The patient also visits their Barangay health Center at Brgy San Juan together with his parents for check-ups.

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PHYSICAL ASSESSMENT
Date and Time of Assessment: July 26, 2011 General Survey: Upon assessing, our patient was sitting on the chair, awake, coherent and responsive to any kind of stimuli. He was not in respiratory distress wearing white sando and short, with good eye to eye contact, with ongoing IVF # 8 of 1000cc PNSS at level of 650cc running at 20gtts/min hooked well on the right metacarpal vein. He is 20 kilograms in weight and 3'9 by height, patients appearance matched his age. Vital Signs: Temperature: 37.9 oC Heart rate: 125bpm Respiratory rate: 25cpm Weight: 20kilograms Height: 119cm or 1.19m BMI= weight(kg)/height (meter2) 20 / 1.19 x 1.19 = 14.12 UNDERWEIGHT Integumentary Petechial rash noted at Left Upper Arm and lower extremities Warm to touch Flushed Skin noted Normal Skin turgor Fair complexion Hair Evenly distributed hair No lice or infestation noted Hair is short and black color Thin and silky hair No dandruff on the scalp noted Capillary refill of 4 seconds Short, dirty nails of both fingers and toes noted Nails are convex curvature with an angle at about 160 degrees Nail texture is smooth Intact epidermis

Nails

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Skull and Face Skull is round Symmetrical face No nodules or masses noted Eyes and Vision Sunken eyeball noted Eyebrows evenly distributed Symmetric in shape (+)PERRLA Coordinated eye movements noted No edema or tenderness over lacrimal gland noted Blink reflex noted Can read students nameplate within 1 meter away Ears and Hearing Auricles color same as facial skin color Symmetric in shape Pinna recoils after it is folded Dry cerumen noted Able to hear ticking of the clock in both ears No difficulty in hearing spoken words Nose and Sinuses Symmetrical and straight No discharges noted Uniform in color as facial skin No lesion noted nose is in midline, patent;internal nares are clean, dark pink with few cilia Oropharynx ( Mouth and Throat) Dry and pale lips noted Cracked lips noted Teeth is yellowish in color Halitosis noted Can swallow food teeth are present,with dental caries; Neck Muscle equal in size, head center Symmetric in shape Can be flexed, hyperextend, laterally flexed and laterally rotates Chest and Thorax chest contour is symmetrical spine is straight no lumps, no masses, no tender areas with clear breath sounds
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patients breathing pattern is normal, with symmetrical chest expansion Both lung fields revealed clear breath sounds upon auscultation No chest pain

Cardiovascular System and Peripheral Vascular System Heart rate audible and within normal range of 125 bpm No edema noted Skin texture resilient and moist Breasts and Axilla Nipples are symmetrical, and everted brown in color No lesions, bruises and masses noted No presence of lymph nodes noted upon palpation in the axilla. Abdomen uniform in color symmetrical contour abdominal pain with pain scale 4/10 Extremities No contractures noted Smooth coordinated movements Equal size on both side of the body No deformities noted

Neurologic system: Patient is oriented to time, place and person ,coherent, awake and responsive. Fully conscious, respond to questions quickly perceptive of events. Makes eye to eye contact, expresses feelings with response to the situation. Cranial Nerves Assessment: Nerve I II III Name Olfactory Optic Oculomotor Function Smell Visual acuity Pupillary reaction Test Have the patient smell a familiar odor Have the patient read the nameplate Shine light in the eye using penlight Follow finger without moving the head Results Patient can identify the smell of orange fruit with blind fold can read students nameplate within 1meter away Pupil is constricted upon focused of light, the six ocular movements are present Can follow finger without moving the
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IV

Trochlear

Eye movement

Trigeminal

Facial sensation

Touch the face

Motor function VI VII Abducens Facial Motor function Motor function Sensory VIII Acoustic Hearing

Muscles of mastication Lateral eye movements Smile,puff checks Tastes Snap fingers by the ear Rhombergs test

Balance

IX X XI

Glossophayngeal Vagus Spinal accessory

Swallowing and voice Vocal cord movement Neck motion

tongue movement Let the patient talk Shoulder shrugging

XII

hypoglossal

Tongue movement and strength

Have the patient move the tongue in circular motion

head, able to move eyeball laterally Patient sensation of skin in face is present, he can differentiate what is blunt , dull and sharp Patient is able to clench his teeth Able to move his eyeball laterally as where the directions of the pencil Able to smile, aise eyebrows, puffed out cheeks,close eyes tightly Can identify various taste like sweet, sour,and salty Can hear the sounds of the snapping finger within .5 meter away from the ear Able to stand with feet together and arms resting at the sides with eyes open and close Able to swallow properly and move his tongue side to side Patient voice is clear and speaks properly Able to move head and can shrug his shoulder against resistance and can turn head to side against resistance Client can protrude tongue midline then can move side to side

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REVIEW OF SYSTEM
Integumentary System No history of skin disease. No history of skin allergy Has history of chicken pox Tag-uko naman sija pagka 4 years old nja,as verbalized by the mother.
Head, Eyes, Ears, Nose, Throat

Has history of headache Has history of nosebleeds Tag sunggo raba na sija mam adtun July 24, 2011 due to hot weather, as stated by the mother

Respiratory System

Patient has no difficulties in breathing.

Cardiovascular System

No history of palpitation No history of heart problems

Genitourinary System

Patient urinates 6 times a day No history of renal disease No difficulty of urination

Gastrointestinal System

Has history of abdominal pain Adtun July 24, 2011sige ngtuwaw ini kay sakit daw ija tijan,stated by the SO.
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no difficulty in elimination at pre-hospitalization Patient had experienced of nausea and vomiting Patient had experienced vomiting of blood Nagsuka lage ini nan dugo adtun July 23 nan buntag, dili sad kun grabe kahamok, as verbalized by the SO.

Patient had experienced loss of appetite Dili man ako ganahan mokaon te, as stated by the patient.

Musculoskeletal System

No history of vehicular accident No history of surgery

Endocrine System

No family history of endocrine problems

Psychiatric No history of Psychiatric disorders

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DOCTORS ORDER
JULY 22, 2011 3:40PM Temp- 37.9C Wt. 20 kg > Please admit child to Pedia Respi Ward > TPR of 4 hours > Labs: -CXR -Urinalysis >IVFS: - D5 NSS 1000cc at 15 gtts/min - D5 0.3 % NaCl 1000cc at 15 gtt/m > Medications: - Paracetamol 250mg/5ml, 5ml every 4 hours RTC - Cefuroxime 600mg IV every 8 hours > Monitor v/s of 4 hours > Refer accordingly > Repeat CBC at 5am tomorrow > Increase fluid intake - Dr. Janice T. PATIO, MDJULY 23, 2011 8:00 AM Temp -36.8C HR-90bpm > Change ongoing IVF to Plain LR 1000cc MFD 150cc > Continue Medications > Transfer of service to Miscellaneous Room > Inform Dr. Gotinga >Intake and Output every shift service
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RR- 22cpm - Dr. Janice T. PATIO, MDJULY 23, 2011 9:00 AM Vomited with blood/blood strict vomitus > Monitor pH/Hct count every 12 hours > Follow IVF with Plain NSS 1 liter to run at 20 gtts/min > Regulate ongoing IVF at 20 gtts/min >For Blood typing - Dr. Cheryl A. Gotinga, MD JULY 23, 2011 9:45 AM > To secure 1 unit of blood of patient blood type and transfuse PRP after proper securing and accurately. - Dr. Cheryl A. Gotinga, MDJULY 24, 2011 10:00 AM Temp- 37.8C RR 36cpm PR- 74bpm - Afebrile with cough noted, epistaxis with adbominal pain (-) watery stool monitor for 8 hours - Dr. Cheryl A. Gotinga, MDJULY 25, 2011 8:00 AM >Follow-up with Plain NSS 1 Liter at 8 hour at upper extension. - Dr. Cheryl A. Gotinga, MDJULY 26, 2011 2:45 PM TEMP 38.50C -febrile >Follow-up with Plain NSS 1 Liter at 8 hour at upper extension. > Follow IVF with PLAIN NSS 1 Liter to run for 8 hours > Nebulize with Salbutamol Inhalation 0.1-0.15 mg/kg/dose 3-4 times a day > Ranitidine 25mg every 8 hours IVTT

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- loss of appetite - Dr. Cheryl A. Gotinga, MDJULY 27, 2011 9:40 PM -afebrile (+) Hermans Sign

>May go home >check-up and repeat CBC, platelet count on Saturday.

- Dr. Cheryl A. Gotinga, MD-

LABORATORY EXAMINATIONS
HEMATOLOGY REPORT

Date: July 22, 2011 @ 1:00PM (Surigao Health Specialist) TEST Hematocrit RESULT 33.9% NORMAL VALUES 40-52 SIGNIFICANCE Anemia

Platelet Count

71 x 109/L

150-400

Thrombocytopenia hemolysis

Date: July 23, 2011 @ 6:50 AM (Caraga Regional Hospital) TEST Hemoglobin Hematocrit RBC Count Platelet Count RESULT 136 g/L 34.3% 4.71 x 1012/L 42 x 109/L NORMAL VALUES 135-175 40-52 4.5-5.2 150-400 SIGNIFICANCE Normal Anemia Normal Thrombocytopenia

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Lymphocytes

55%

15-35

Infection Increased due to the bodys increased immune system

Date: July 23, 2011 @ 9:45 PM (Caraga Regional Hospital) TEST Hemoglobin Hematocrit RBC Count Platelet Count BLOOD TYPE : A+ Date: July 24, 2011 @ 6:00 AM (Caraga Regional Hospital) TEST Hematocrit Platelet Count RESULT 41% 41 x 109/L NORMAL VALUES 40-52 150-400 SIGNIFICANCE Normal Thrombocytopenia RESULT 151 g/L 37.9% 5.15 x 1012/L 27 x 109/L NORMAL VALUES 135-175 40-52 4.5-5.2 150-400 SIGNIFICANCE Normal Anemia Normal Thrombocytopenia

Date: July 24, 2011 @ 10:40 PM (Caraga Regional Hospital) TEST Hematocrit Platelet Count RESULT 39% 33 x 109/L NORMAL VALUES 40-52 150-400 SIGNIFICANCE Near Normal Thrombocytopenia

Date: July 25, 2011 @ 6:00 AM (Caraga Regional Hospital) TEST Hematocrit Platelet Count RESULT 36.7% 45 x 109/L NORMAL VALUES 40-52 150-400 SIGNIFICANCE Anemia Thrombocytopenia
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Date: July 26, 2011 @ 6:00 AM (Caraga Regional Hospital) TEST Hematocrit Platelet Count RESULT 37% 66x 109/L NORMAL VALUES 40-52 150-400 SIGNIFICANCE Anemia Thrombocytopenia

Date: July 27,2011 @ 6:00 AM (Caraga Regional Hospital) TEST Hematocrit Platelet Count RESULT 37% 66x 109/L NORMAL VALUES 40-52 150-400 SIGNIFICANCE Anemia Thrombocytopenia

URINALYSIS

Date: July 23, 2011 @ 11:00 AM (Caraga Regional Hospital) RESULT

Color Sugar Transparency Specific gravity Yellow Negative Clear 1.020

NORMAL VALUES Yellow-amber Negative Clear 1.010-1.030 Negative 6.5-7.5

SIGNIFICANCE Normal Normal Normal normal Normal normal

Protein Ph

Negative 6.7

Aline B. Palermo, RMT Medical Technologist

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ANATOMY AND PHYIOLOGY

BLOOD is considered the essence of life because the uncontrolled loss of it can result to death. Blood is a type of connective tissue, consisting of cells and cell fragments surrounded by liquid matrix which circulates through the heart and blood vessels. The cells and cell fragments are formed elements and the liquid is plasma. Blood makes about 8% of total weight of the body. Functions of Blood: >transports gases, nutrients, waste products, and hormones >involve in regulation of homeostasis and the maintenance of PH, body temperature, fluid balance, and electrolyte levels >protects against diseases and blood loss Plasma Plasma is a pale yellow fluid that accounts for over half of the total blood volume. It consists of 92% water and 8% suspended or dissolved substances such as proteins, ions, nutrients, gases, waste products, and regulatory substances. Plasma volume remains relatively constant. Normally, water intake through the GIT closely matches water loss through the kidneys, lungs, GIT and skin. The suspended and dissolved substances come from the liver, kidneys, intestines, endocrine glands, and immune tissues as spleen. FORMED ELEMENTS Cell Type Erythrocytes (RBC) Description Biconcave disk, no Function Transport oxygen and carbon
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nucleus,7-8 micrometers in diameter

dioxide

Leukocytes (WBC):

Neutrophil Spherical cell, nucleus with two or more lobes connected by thin filaments, cytoplasmic granules stain a light pink or reddish purple, 12-15 micrometers in diameter

Phagocytizes microorganism

Basophil

Spherical cell, nucleus, with two indistinct lobes, cytoplasmic granules stain blue-purple, 10-12

Releases histamine, which promotes inflammation, and heparin which prevents clot formation
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micrometers in diameter

Eosinophil

Spherical cell, nucleus often bilobed, cytoplasmic granules satin orange-red or bright red, 10-12 micrometers in diameter

Releases chemical that reduce inflammation, attacks certain worm parasites

Lymphocyte

Spherical cell with round nucleus, cytoplasm forms a thin ring around the nucleus, 6-8 micrometers in diameter

Produces antibodies and other chemicals responsible for destroying microorganisms, responsible for allergic reactions, graft rejection, tumor control, and regulation of the immune system.

Monocyte

Spherical or irregular cell, nucleus round or kidney or horse-shoe shaped, contain more cytoplasm than lymphocyte, 10-15 micrometers in diameter

Phagocytic cell in the blood leaves the circulatory system and becomes a macrophage which phagocytises bacteria, dead cells, cell fragments, and debris within tissues

Platelet

Cell fragments surrounded by a cell membrane and containing granules, 2-5

Forms platelet plugs, release chemicals necessary for blood

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micrometers in diameter

clotting

PREVENTING BLOOD LOSS When a blood vessel is damaged, blood can leak into other tissues and interfere with the normal tissue function or blood can be lost from the body. Small amounts of blood from the body can be tolerated but new blood must be produced to replace the loss blood. If large amounts of blood are lost, death can occur.
BLOOD CLOTTING

Platelet plugs alone are not sufficient to close large tears or cults in blood vessels. When a blood vessel is severely damaged, blood clotting or coagulation results in the formation of a clot. A clot is a network of thread. The formation of a blood clot depends on a number of proteins found within plasma called clotting factors. Normally the clotting factors are inactive and do not cause clotting. Following injury however, the clotting factors are activated to produce a clot. This is a complex process involving chemical reactions, but it can be summarized in 3 main stages; the chemical reactions can be stated in two ways: just as with platelets, the contact of inactive clotting factors with exposed connective tissue can result in their activation. Chemicals released from injured tissues can also cause activation of clotting factors. After the initial clotting factors are activated, they in turn activate other clotting factors. A series of reactions results in which each clotting factor activates the next clotting factor in the series until the clotting factor prothrombin activator is formed. Prothrombin activator acts on an inactive clotting factor called prothrombin. Prothrombin is converted to its active form called thrombin. Thrombin converts the inactive clotting factor fibrinogen into its active form, fibrin. The fibrin threads form a network which traps blood cells and platelets and forms the clots. dlike protein fibers called fibrin, which traps blood cells, platelets and fluids. CONTROL OF CLOT FORMATION Without control, clotting would spread from the point of its initiation throughout the entire circulatory system. To prevent unwanted clotting, the blood contains several anticoagulants which prevent clotting factors from forming clots. Normally there are enough anticoagulants in the blood to prevent clot formation. At the injury site, however, the stimulation for activating clotting factors is very strong. So many clotting factors are activated that the anticoagulants no longer can prevent a clot from forming.
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CLOT RETRACTION AND DISSOLUTION After a clot has formed, it begins to condense into a denser compact structure by a process known as clot retraction. Serum, which is plasma without its clotting factors, is squeezed out of the clot during clot retraction. Consolidation of the clot pulls the edges of the damaged vessels together, helping the stop of the flow of blood, reducing the probability of infection and enhancing healing. The damaged vessel is repaired by the movement of fibroblasts into damaged area and the formation of the new connective tissue. In addition, epithelial cells around the wound divide and fill in the torn area. The clot is dissolved by a process called fibrinolysis. An inactive plasma protein called plasminogen is converted to its active form, which is called plasmin. Thrombin and other clotting factors activated during clot formation, or tissue plasminogen activator released from surrounding tissues, stimulate the conversion of plasminogen to plasmin. Over a period of a few days the plasmin slowly breaks down the fibrin.

28

PATHOPHYSIOLOGY
PREDISPOSING FACTORS: Age (child) Sex (male) PRECEPITATING FACTORS: Environment: Dirty backyard and open canal drainage Uncovered Water Containers Chikungunya Virus Dengue Virus Type 1, 2, 3, &4

Race (Asian)
Endemic area of Dengue Fever Infection of the liver

Bite of an aedes aegypti mosquito carrying a virus Compression of the stomach Production of matured blood component Accumulation of virus to capillary

Capillary
Permeability

Nausea and Vomiting

Loss of appetite of virus to the Circulatory System Spread Decreased platelet Fever: 37.90C production

Abdominal Pain

Immune Response

Hematology: Platelet Count: 71 x 109/L

Cytokines Released

Destruction of cells (Platelet)

Decreased viscosity of the blood

Decreased coagulation factor

Lysis

Inflammation Bleeding

Petechiae Epistaxis

Sequestrations in the liver and spleen

Hematemesis Production of non-neutralizing antibodies

DENGUE HEMORRHAGIC FEVER

Accumulation of dead cells in the organ

Medical Management Medications Paracetamol Tempra Ampicillin Hematology: Ranitidine Lymphocytes: Infection Intravenous Fluid 55% 1000 cc PNSS 1000 cc D5 0.3 NaCl

Nursing Care Management Laboratory exam Hematology Urinalysis Platelet Transfusion

29

Infection of the spleen

Legend:
Pathophysiology Manifestation Sign and Symptoms Final Diagnosis Medical Management Flow of Pathophysiology

GOOD PROGNOSIS

DRUG STUDY
30

Date Ordered: July 22, 2011

Generic Name

Paracetamol Brand Name Tempra Classification Nonopoid analgesic

Prescribed and Recommended 250 mg/5ml q 4 hours x PRN for fever Dosage, Frequency and Route of Administration

Mechanism of Therapeutic effect: relieves pain and reduces fever. Actions Chemical effect: may produce analgesic effect by blocking pain impulses, by inhibiting prostaglandin or pain receptor sensitizers. May relieve fever by acting in hypothalamic heat-regulating center. Indications Mild pain or fever Contraindications Contraindicated in patients hypersensitive to drug. Patient undergoing long term therapy for chronic non congestive angle-closure glaucoma, and patients with hypothermia, renal or hepatic impairment adrenal gland failure and hypercloremic acidosis. Adverse Reactions CNS: drowsiness, paresthesia GU: nausea and vomiting Hematologic: hemolytic anemia, neutropenia, leucopenia, pancytopenia, thrombocytopenia Hepatic: liver damage Metabolic: hypoglycemia Nursing 1. Assess patients pain or temperature before and during therapy. Consideration 2. Assess patients drug history. Many OTC products and combination prescription pain products contain acetaminophen. Calculate daily dosage accordingly. 3. Be alert for adverse reactions and drugs interactions.

Date Ordered: July 24, 2011

31

Generic Name

Ranitidine
Brand Name Classification Prescribed and Recommended Dosage, Frequency and Route of Administration Mechanism of Actions

Zantac Anti-ulcerative 25mg IVTT q 8 hours Therapeutic Effect: relieves GI discomfort Chemical Effect: competitively inhibits action if H2 at receptor sites of

parietal cells, decreasing gastric acid secretion. Indications Duodenal and gastric ulcer Gastroesophangeal reflux disease
Contraindications Contraindicated in patients hypersensitive to the drug or any of its components. Adverse Reactions CNS: headache, fatigue CV: chest pain GI: nausea and vomiting, abdominal pain Nursing Consideration

1. 2. 3. 4.

Assess patients GI condition before starting therapy and regularly thereafter to monitor the drugs effectiveness. Be alert for adverse reactions and drug interactions. Assess patients and familys knowledge therapy. Instruct patients not to drink alcohol during therapy.

32

Date Ordered: July 24, 2011

Generic Name

Recommended Dosage, Frequency and Route of Administration Mechanism of Relaxes smooth muscles by stimulating beta2-receptors, thereby causing Actions bronchodilation and vasodilation Indications To prevent and relieve bronchospasm in patients with reversible obstructive Contraindications Adverse Reactions

Salbutamol Brand Name Ventolin Classification Bronchodilator Prescribed and 0.1-0.15 mg/kg/dose 3-4 times a day

Nursing Consideration

airway disease Hypersensitivity to albuterols CNS: dizziness, excitement, headache,hyperactivity, insomnia CV: hypertension, palpitations, tachycardia,chest pain EENT: conjunctivitis, dry and irritated throat, pharyngitis GI: nausea, vomiting, anorexia, heartburn, GI distress, dry mouth Metabolic: hypokalemia Musculoskeletal: muscle cramps Respiratory: cough, dyspnea, wheezing,paradoxical bronchospasm Skin: pallor, urticaria, rash, angioedema, flushing, sweating Other: tooth discoloration, increased Stay alert for hypersensitivity reactions and paradoxical broncho spasm. Stop drug immediately if these occur. Monitor serum electrolyte levels. Encourage back tapping after nebulizing

Date Ordered: July 22, 2011

33

Generic Name

Cefuroxime Brand Name Cefuroxime sodium (Zinacef) Classification Antibiotic Cephalosporin (second generation)
Prescribed and Recommended Dosage, Frequency 600 mg IV every 8 hours and Route of Administration Mechanism of Bactericidal: Inhibits synthesis of bacterial cell wall, causing cell death. Actions Indications Prophylaxis against infection in abdominal where there is increased risk from

infections.
Contraindications Contraindicated in patients hypersensitive to drug or other cephalosprins

Use cautiously in patients with history of sensitivity to penicillin and in patients renal impairment. Adverse Reactions CNS: dizziness,headache,malaise, paresthesia GI: bdominal cramps, anal pruritus, anorexia,diarrhea, nausea GU: genital pruritus and candidiasis Hematologic: eosinophilia,hemolytic anemia Respi: dyspnea
Nursing Instruct patient to take drug exactly as prescribed Consideration

advise patient to take oral drug with food to enhance absorption tell the patient to report adverse reactions.

NURSING CARE PLAN 1

Date: July 26, 2011 Time: 7 am 3pm 34

Objective Cues: Warm to touch Temp: 37.90C Flushed skin noted restlessness noted Nursing Diagnosis: Altered body temperature: hyperthermia related to infection process secondary to Dengue Hemorrhagic Fever Grade II. Planning: Within 30 minutes of rendering nursing intervention, the patients body temperature will decrease from normal range of 36C to 37.4 C. IMPLEMENTIONS: Independent 1. Monitored patients temperature (degree and pattern). 2. Provided tepid sponge bath. 3. Loosened blankets and clothes. 4. Advised the patient to increase fluid intake. Rationale In order to have a baseline for subsequent examination. May help reduce fever. Tight clothing can increase body temperature. Fluid loss contributes to fever Rationale Use to reduce fever by its central action on the hypothalamus; however, fever may be beneficial in limiting growth of organisms and enhancing auto destruction of infected cells. Rationale Hyperthermia increases metabolic demand for oxygen To promote rapid core cooling.

Dependent
1. Administered antipyretic as prescribed: Paracetamol (tempra) 250 mg/5ml q 4 hours

x PRN for fever

Ideal 1. Provide oxygen therapy in extreme cases. 2. Monitor use of hypothermia blanket and wrap extremities with bath towels. Evaluation:

Goal met. After 30 minutes of rendering nursing intervention, the patient body temperature has been decreased to 37.30C.

NURSING CARE PLAN # 2

Date: July 26, 2011 Time: 7am 3pm 35

Subjective Cue: Objective Cues: Low platelet count of 66 x 109 g/L Petechial rash noted at left upper arm and lower extremities

Nursing Diagnosis: High Risk for injury related to abnormal blood profile of thrombocytopenia Planning: Within 8 hours of rendering nursing intervention, the patient will be free of injury. IMPLEMENTIONS: Independent 1. Noted age and sex 2. Identify interventions/ safety devices such as soft toothbrush 3. Encouraged patient to gargling a cup of water with 2 drops of oral care than using toothbrush to have oral hygiene. Evaluation: After 8 hours of nursing interventions, the patient is safe from bleeding with safety environment. Goal met. Rationale Children, young, adults, elderly persons and men are greater risk. To promote safe physical environment and individual safety. To prevent the patient from bleeding.

NURSING CARE PLAN # 3

Date: July 26, 2011 Time: 7am 3pm 36

Subjective Cue: Ate sakit lage ako tijan, as verbalized by the patient. Objective Cues: Abdominal guarding Grimace face noted irritability noted Sweating Pain scale as 4/10 Loss of appetite

Nursing Diagnosis: Comfort, Altered: Pain, acute related to changing appetite and eating Planning: Within 4 hours of rendering nursing intervention, the patient will be able to verbalized relief of pain from pain scale of 4/10 to 0/10. IMPLEMENTIONS: Independent 1. Assessed for pain every 30 minutes. 2. Reviewed factors that aggravate or alleviate pain. 3. Encouraged use of relaxation techniques (e.g., Jaw relaxation, Slow rhythmic breathing and simple imagery. 4. Note nonverbal pain cues (e.g, restless, abdominal guarding and tachycardia). 5. Encouraged activity/exercise within limits of individual ability. Evaluation: Partially met. After 4 hours of nursing interventions, the patient verbalized of pain with pain scale of 2. Rationale Pain is not always present, but if it is present should be compared with patients previous pain symptoms. Helpful in establishing diagnosis and treatment need. Help patient to rest effectively and refocuses attention, thereby reducing pain and discomfort. Nonverbal cues may be both physiologic and Psychologic and maybe used in conjunction with verbal cues to evaluate severity of the problem. To stimulate contractions of the intestines.

NURSING CARE PLAN # 4

Date: July 27, 2011 Time: 7am 3pm 37

Subjective Cue: Maam dili pa gajud makaligo ako bata kay tag luja pa iya lawas tapos dili pa cja kabangon as verbalized by the SO. Objective Cues: Long, untrimmed nails on the fingers. Halitosis noted Unable to perform simple self-care activities Dry cracked lips Weakness

Nursing Diagnosis: Self-care deficit: Bathing and oral hygiene related to decreased motivation. Planning: Within 3 hours of rendering nursing intervention the patient will be able to perform self care activities (e.g., bathing, grooming and dressing). IMPLEMENTIONS: Independent 1. Determined clients strengths and skills. 2. Provided privacy during personal care activities. 1. 3. Provided bed tepid sponge bath to the client. 2. 4. Trimmed the nails of the client. 3. 5. Changed client soiled clothes. 4. 6. Assisted SO in providing oral care. 5. 7. Provided SO with health teaching regarding of proper hygiene for the patient. Evaluation: Rationale To assess degree of disability. Its the right of the patient. To protect patients dignity. To promote hygiene and prevent further infection. To promote comfort and enhance patients well being. To promote hygiene and prevent halitosis. To promote knowledge and awareness.

After 3 hours of nursing intervention, the patient still needs assistance in performing such activities concerning self-care (e.g., bathing, grooming and dressing).Goal was partially me.

NURSING CARE PLAN # 5

Date: July 26, 2011 Time: 7 am- 3pm Subjective Cue: Ate dukag lage ako panit , as verbalized by the S.O. 38

Objective Cues: Petechial rash noted at left upper arm and lower extremities Facial grimace Irritability dry skin Itchiness noted Nursing Diagnosis: Impaired Skin Integrity related to immunological as evidenced by itchiness. Planning: Within 4 hours of rendering quality nursing intervention the patient will be able to verbalize that itchiness are gone. IMPLEMENTIONS: Independent 1. Inspected all skin areas, rotting capillary blanching or refill of 4 seconds. 2. Keep bed clothes dry and free of wrinkles. 3. Advised the patient to take a bath and pat dry skin. 4. Assessed skin color. 5. Repositioned frequently whether in bed or sitting position. Ideal Rationale Skin is especially prone to break down because of changes in peripheral circulation. Reduces or prevent skin irritation. Clean dry skin is less prone to excoriation or break down. Skin color should be similar to color of surrounding skin. Improves skin circulation and reduces pressure.

Rationale Improves systemic and peripheral circulation, 1. Provide kinetic therapy or altering pressure decreases pressure on skin and reducing of break mattress as indicated. down. 2. Administer fluids, electrolytes, nutrients, and To promote optimal blood flow, organ perfusion, and oxygen as indicated. function. Evaluation: Goal partially met. After 4 hours of nursing interventions, the patient experience less itchiness on his skin.

NURSING CARE PLAN 6

Date: July 26, 2011 Time: 7am 3pm Subjective Cue: Maam dili man ganahan mokaon ako bata as verbalized by the SO. Objective Cues: 39

Nausea and vomiting Loss of appetite Weakness noted BMI: underweight 14.12

Nursing Diagnosis: Altered nutrition, less than the body requirements related to loss of appetite. Planning: Within 8 hours of rendering nursing intervention, the patient will be able to cooperate and take his meals of 1 cup of rice, 1 slice of mango, cup of kare-kare and 1 piece of fried chicken. IMPLEMENTIONS: Independent 1. Obtain a through nutritional assessment. 2. Resumed solid foods slowly. 3. Provided oral hygiene before meals if tolerated. 4. Weigh as indicated. 5. Consult with patient about likes or dislikes, and preferred meal schedule. 6. Recommend rest before meals. 7. Provide high protein diet, with individually approved complex carbohydrates and calories, nutritious foods with supplements between meals. 8. Encouraged patient to verbalized feelings concerning resumption of diet. Rationale Identified deficiencies or needs to aid in choice of intervention.. . Reduces incidence of abdominal cramps, nausea. A clean mouth enhances appetite. Monitor effectiveness of dietary plan. Involving patient in planning enables patient to have a sense of control and encourages eating. Quiets peristalsis and increases available energy for eating. Adjustments may be needed to deal with the bodys decreased ability to process protein, as well as decreased metabolic rate and level of activity. Hesitation to eat may be result of fear that food will cause exacerbation of symptoms.

Evaluation: After 8 hours of nursing intervention, the patient was able to cooperate and take his meals. Goal was met.

NURSING CARE PLAN 7

Date: July 26, 2011 Time: 7am 3pm 40

Subjective Cue: Maam waya gihapon cja ka libang gikan pa pag-admit as verbalized by the S.O. Objective Cues: Hypoactive bowel sounds: 2 bowel sounds per minute Abdominal pain No bowel movement for 2 days

Nursing Diagnosis: Constipation related to inadequate physical activity and insufficient fiber in diet Planning: Within 8 hours of nursing interventions, the patient will able to defecate. IMPLEMENTIONS: Independent 1. Auscultate bowel sounds. 2.Encourage fluid intake of 2500-3000ml/day within cardiac tolerance. 3. Recommend avoiding gas forming foods. 4. Encourage to eat high-fiber rich foods. 5. Encourage activity/exercise within limits of individual ability. Ideal 1. Consult with dietitian to provide well balanced diet high in fiber and bulk.

Rationale Bowel sounds are generally decreased in constipation.

Assists in improving stool consistency. Decrease gastric distress and abdominal distension. To enhance easy defecation. To stimulate contractions of the intestines. Fiber resists enzymatic digestion and absorbs liquids in its passage along the intestinal tract and thereby produces bulk, which acts as a stimulant to defecation.

Evaluation: After 8 hours of nursing interventions, the patient was not able to defecate. Goal unmet.

DISCHARGE PLAN
Date of Discharge: July 27, 2011
Upon discharge from the hospital, the patient and SO will be given home care instructions containing the following: MEDICATION: Continue taking medicine prescribe by the physician as:

41

 Cefuroxime 250 mg/5ml 1 tsp 2 x a day for 7 days after breakfast and after supper ENVIRONMENT: Canal drainage must be clean and always covered. Advised SO to keep environment clean and free from any form of infection. Advised SO to keep good environment measures to prevent mosquito breeding. TREATMENT: Advised SO not to stop the maintenance medicine unless prescribed by the physician. Encourage SO to follow treatment regimen and explain to them the importance of taking the medication religiously. HEALTH TEACHINGS: Advised the SO: Use mosquito repellants on skin and clothing Clean up inside and outside the house weekly. Always cover the water containers, to avoid the mosquito to stay in. Disposed the unused tires. To clean area with stagnant water Control sewage. Using a mosquito coil on day and night time Clean water container weekly Bury rubbish Bury water containers Dress in protective clothinglong-sleeved shirts, long pants, socks, and shoes Schedule outdoor activities for times when mosquitoes are less prevalent Stay in air-conditioned or well-screened housing Avoiding outdoor activities at dawn and dusk OUTPATIENT FOLLOW-UP CHECK-UP: Instruct the patient SO for follow-up check-up on July 30, 2011 at OUT PATIENT DEPARTMENT OF Caraga Regional Hospital. DIET: Instruct the SO to let the patient eat nutritious foods such as vegetables, fruits, fish, low fat dairy products, 3-4 glasses of milk, lean meat and cheese or yogurt to meet there calcium needs. Instruct the SO to let the patient drink plenty of water of 8-10 glasses or 2.5-3 ml a day. SPIRITUAL: Instruct the SO to have strength and faith in GOD. Instruct the SO to always keep on praying and be thankful to GOD because GOD answers wiser to our prayer and attend the masses every SUNDAY.

DEFINITION OF TERMS
Agglutinogens antigen that stimulate the formation of a specific agglutinin; antigens found on RBC that are responsible for determining the ABO blood group classification.
42

Agranulocytes lack visible cytoplasmic granules. Their nuclei are closer to the norm-that is, they are spherical, oval or kidney shaped. Albumin contributes to the osmotic pressure of blood, w/c acts to keep water in the blood stream; clotting proteins help stem blood loss when a blood vessel is injured and anti-bodies help protect the body from pathogens. Antibody specialized substance produced by the body that can provide immunity against a specific antigen. Antigen a substance that the body recognizes as foreign; it stimulates the immune system to release antibodies or use other means to mount a defense against it. Basophils white blood cells whose granules stain deep blue with basic dye; have a relatively pale nucleus and granular-appearing cytoplasm. Eosinophils granular white blood cells whose granules readily take up a stain called eosin. Erythrocytes function primarily to ferry oxygen in blood to all cells of the body. Granulocytes are granule containing WBCs. Typically consist of several rounded nuclear areas connected by thin strands of nuclear material.

Hemoglobin (Hgb) applies to severe different hereditary bleeding disorders that results from a lack of any of the factors needed for clotting.

43

Leukocytes or White Blood Cells (WBC) are far less numerous than red blood cells, they are crucial to the body defense against disease. Lymphocytes - have a large dark purple nucleus that occupies most of the cell volume. Only slightly larger than RBCs lymphocytes tend to take up residence in lymphatic tissues, where they play an important role in the immune response. Monocytes are the largest of the WBCs. Except for their more abundant cytoplasm and indented nucleus, they resemble large lymphocytes. Neutrophils have a multi lobed nucleus and very fine granules that respond to both acid and basic stains. The most abundant in the white blood cells. Plasma the fluid portion of the blood. Platelet - on of the irregular cell fragments of blood; involved in clotting. Thrombocytopenia results from an insufficient number of circulatory platelets.

APPENDICES
INTAKE AND OUTPUT MONITORING SHEET
44

July 23, 2011 SHIFT 7-3 3-11 11-7 total 590cc ORAL

Intake PARENTERAL TOTAL

Output URINE STOOL TOTAL

500cc

1090cc

530cc

530cc

1090cc

530cc

July 24, 2011 July 25, 2011 SHIFT SHIFT 7-3 7-3 3-11 3-11 11-7 11-7 total

Intake Intake ORAL ORAL 200cc 550cc 500cc 550cc 2500cc PARENTERAL PARENTERAL 370cc 450cc 400cc 840cc 250cc TOTAL TOTAL 570cc 1000cc 900cc 1390cc 500cc 1970cc 2390cc

Output Output URINE URINE 150cc 300cc 200cc 200cc 170cc STOOL STOOL 1X TOTAL TOTAL 150cc 300cc 200cc 200cc 170cc 520cc 500cc

July 26, 2011 SHIFT 7-3 ORAL 1200cc

Intake

Output

PARENTERAL 200cc

TOTAL 1400cc

URINE 350cc

STOOL

TOTAL 350cc 2xBM

3-11

1000cc

250cc

1250cc

300cc

2x

300cc 2xBM 280cc 930cc 4xBM

11-3 total

500cc

500cc

1000cc 3650cc

280cc

VITAL SIGNS
45

Date: JULY 26, 2011 Shift: 7-3 pm V/S TEMPERATURE HEART RATE RESPIRATORY RATE 8AM 37.9C 125bpm 25cpm 12NN 37.3C 110bpm 23cpm

Date: JULY 27, 2011 Shift: 7-3 pm V/S TEMPERATURE HEART RATE RESPIRATORY RATE 8AM 36.5C 128bpm 28cpm 37C 121mb 31bpm 12NN

INTRAVENOUS FLUID SHEET

Date Bottle # Solution Volume Flow Rate Time Infused Time Consumed July 22, 2011 1 1000cc D5 0.3 NaCl 15gtts/min 4:00pm 8:30am July 23, 2011 July 23, 2011 2 1000cc D5 0.3 NaCl 15gtts/min 8:35am 1:05am
46

July 23, 2011 July 24, 2011 3 1000cc PNSS 20gtts/min 1:10am 1:40pm July 24, 2011 July 24, 2011 4 1000cc PNSS 20gtts/min 1:45pm 2:15am July 25, 2011 July 25, 2011 5 1000cc PNSS 20gtts/ min 2:20am 2:50pm July 25, 2011 July 25, 2011 6 1000cc PNSS 20gtts/min 2:55pm 3:45am July 26, 2011 July 26, 2011 7 1000cc PNSS 20gtts/ min 3:50am 4:20pm July 26, 2011 July 26, 2011 8 1000cc PNSS 20gtts/min 4:25pm 4:55am July 27, 2011 July 27, 2011 9 1000cc PNSS 20gtts/min 5:00am 2:30pm terminated July 27, 2011

47

REFERENCE
Books Kozier (2002) Fundamentals of Nursing: Concept, Process and Practice, 8th Edition. Marilynn E. Doenges (1997) Nursing Care Plans: Guidelines for individualizing patient care. MARY FRANCES MOORHOUSE & ALICE C. GEISSLER Francisco T. Duque III, MD, MSC (2007) Public Health Nursing in the Philippines, 10th Edition. Lippincott Williams & Wilkins (2007) Nurses Drug Guide 2010 by Amy M. Karch, RN, MS Elaine N. Marieb (2006) Essential of Human Anatomy and Physiology, 8th Edition. Nurses Pocket Guide 10th Edition Marilynn E. Doenges, Mary Frances and Alice C. Murr Merriam- Websters Medical Dictionary MOSBYS Nursing PDQ 2004 Edition Practical Detailed Quick MIMS 104th edition 2005 Public Health Nursing in the Philippines 10th edition copyright 2007 printed 2007 editor in chief Frances Prescilla L. Cuevas, RN, MAN page 264-267 Nursing Care Plans, nursing diagnosis and intervention 3rd edition, (Gulanack,klopp,galanes,gradishar,puzas) copyright 1994 by Mosby-year book,inc. ELECTRONICS SOURCES www.encarta.com http :// bsnurse.com/?p =1949 http:// www.mb.com.ph /node/317909 caraga-inten http:// www. rmnews.com/ beta/news/regional/16493-kaso-sa-dengue-sa-caraga-region-bumaba- sa 70. html
48

http:// www. dhpe.org/infect/dengue/html.

PRESENTORS PROFILE
NAME: BAUTISTA, Lionel Philip Fernandez AGE: 23 years old ADDRESS: Surigao Medical Center Compound,Surigao City BIRTHDAY: November 18, 1987 BIRTHPLACE: Surigao City EDUCATIONAL BACKGROUND

ELEMENTARY: Surigao Education Center HIGHSCHOOL: Surigao Education Center COLLEGE: Surigao Education Center

49

NAME: BITACURA, Leah Catherine Ebol AGE: 20 years old ADDRESS: Purok Madasigon Brgy. Washington, Surigao City BIRTHDAY: January 18, 1991 BIRTHPLACE: Surigao City

EDUCATIONAL BACKGROUND

ELEMENTARY: Luna Elementary School HIGHSCHOOL: Don Ruben E. Ecleo Memorial National High school COLLEGE: Surigao Education Center

50

NAME: CABAA, Elvie Casalta AGE: 19 years old ADDRESS: 01151 Ortiz, Kaskag, Brgy. Washington, Surigao City BIRTHDAY: December 12, 1991 BIRTHPLACE: Surigao City EDUCATIONAL BACKGROUND

ELEMENTARY: Surigao City Pilot School HIGHSCHOOL: Surigao Norte National High School COLLEGE: Surigao Education Center

51

NAME: CUSTODIO, Irish Linaga AGE: 25 years old ADDRESS: Block 10 Lot 17 Mana Pepang Village Brgy. Rizal Surigao City BIRTHDAY: October 12, 1985 BIRTHPLACE: Brgy. Sidlakan, Surigao City EDUCATIONAL BACKGROUND

ELEMENTARY: Sidlakan Elementary School HIGHSCHOOL: Surigao Norte National High School COLLEGE: Surigao Education Center

52

NAME: FELICITAS, Dassyl Noble AGE: 23 years old ADDRESS: Purok 4 Brgy. Mabua, Surigao City BIRTHDAY: July 18, 1988 BIRTHPLACE: Surigao City EDUCATIONAL BACKGROUND

ELEMENTARY: Mabua Elementary School HIGHSCHOOL: Ipil National High School COLLEGE: Surigao Education Center

53

NAME: GORDUIZ, Novie Michelle Aldonza AGE: 19 years old ADDRESS: Km. 3 Checkpoint Brgy. Luna, Surigao City BIRTHDAY: November 26, 1991 BIRTHPLACE: Surigao City EDUCATIONAL BACKGROUND

ELEMENTARY: Surigao City Pilot School HIGHSCHOOL: Northeastern Mindanao Colleges COLLEGE: Surigao Education Center

NAME: LITERATO, Cherremae Golindang AGE: 20 years old

54

ADDRESS: 521 Arellano St., Dapa, Surigao del Norte BIRTHDAY: May 4, 1991 BIRTHPLACE: Quezon City, Manila

EDUCATIONAL BACKGROUND

ELEMENTARY: Don Enrique Navarro Memorial School HIGHSCHOOL: San Nicolas School COLLEGE: Surigao Education Center

NAME: MARTINEZ, Jureza AGE: 23 years old ADDRESS: Purok -7 Sitio Looc, Brgy. Mabua, Surigao City
55

BIRTHDAY: June 14, 1988 BIRTHPLACE: Brgy. Catbawan, Pintuyan, Southern Leyte EDUCATIONAL BACKGROUND

ELEMENTARY: Punta Bilar Elementary School HIGHSCHOOL: Ipil National High School COLLEGE: Surigao Education Center

NAME: PILONGO, CESAR DELOS SANTOS Jr. AGE: 21 years old ADDRESS: Purok Mabongahon, Interior Capitol Road, Brgy. Washington, Surigao City
56

BIRTHDAY: May 1, 1990 BIRTHPLACE: Lawigan, Bislig City EDUCATIONAL BACKGROUND

ELEMENTARY: Tumanan Elementary School HIGHSCHOOL:Surigao Norte National High School COLLEGE: Surigao Education Center

NAME: SALVALOZA, Jobelle Gonzales AGE: 23 years old ADDRESS: Nueva Extension, Brgy. Taft, Surigao City BIRTHDAY: July 2, 1988 BIRTHPLACE: Antipolo, Del Carmen, Surigao del Norte
57

EDUCATIONAL BACKGROUND

ELEMENTARY: Pilar Central Elementary School HIGHSCHOOL: Saint Paul University Surigao COLLEGE: Surigao Education Center

NAME: SITOY, Maria Jessa Eludo AGE: 21 years old ADDRESS: Block 4 Lot 18 Canlanipa Homes, Surigao City BIRTHDAY: September 13, 1989 BIRTHPLACE: Surigao City

58

EDUCATIONAL BACKGROUND

ELEMENTARY: Cagdianao Central Elementary School HIGHSCHOOL: Cagdianao National High School COLLEGE: Surigao Education Center

NAME: VIRTUDEZ, Richard Montalban AGE: 23 years old ADDRESS: Purok-4 Brgy. San Juan, Surigao City BIRTHDAY: February 25, 1988 BIRTHPLACE: Surigao City EDUCATIONAL BACKGROUND
59

ELEMENTARY: Surigao West Central Elementary School HIGHSCHOOL: Surigao City National High School COLLEGE: Surigao Education Center

60