Holy Angel University

College of Nursing Angeles City

In Partial fulfilment of the Requirements In Related Learning Experience III Angeles Medical Center

Dengue Fever
Case study
Submitted by: N304 Group 4 Cabatbat, Ruffa Cutillion, Ar-j Laxamana, Clarenz Maniulit, Joel Marcos, Jheremy Muega, Raquel Sese, Nico Sicat, Kathleen Victoriano, Francis

Submitted to: Dra. Eliezer Dizon RN MAN

21 January 2012

I. INTRODUCTION

A. Statistics

Dengue is transmitted by the bite of an Aedes Aegypti mosquito infected with anyone of the four dengue viruses. It occurs in tropical and sub-tropical areas of the world. Symptoms appear 314 days after the infective bite. Dengue fever is a febrile illness that affects infants, young children and adults. The incidence of dengue has grown dramatically around the world in recent decades. Some 2.5 billion people two fifths of the world's population are now at risk from dengue. WHO currently estimates there may be 50 million dengue infections worldwide every year. In 2007 alone, there were more than 890 000 reported cases of dengue in the Americas, of which 26 000 cases were DHF. Not only is the number of cases increasing as the disease is spreading to new areas, but explosive outbreaks are occurring. In 2007, Venezuela reported over 80 000 cases, including more than 6 000 cases of DHF. Without proper treatment, DHF fatality rates can exceed 20%. Wider access to medical care from health providers with knowledge about DHF - physicians and nurses who recognize its symptoms and know how to treat its effects - can reduce death rates to less than 1%. (http://www.who.int/mediacentre/factsheets/fs117/en/, retrieved January 19, 2012) The press release of the Department of Health (DOH) last August 12, 2010 on dengue statistics in the Philippines was very alarming. According to DOH, the number of dengue cases has roused to 48% from January to the last day of July this year, recording a total of 40, 648 cases. (http://your-daily-feed.blogspot.com/2010/08/dengue-information-in-philippines.html,

retrieved January 20, 2012)

B. Objectives

After completing this case study, the student nurses will be able to:

1) Discuss comprehensively the pathophysiology of Dengue Fever. 2) Gather significant information as to the level of patients understanding and economic status. 3) Make a nursing care plan related and significant to the patients condition. 4) Utilize the nursing care plan in meeting the needs of the patient. 5) Work collaboratively with the members of the health team and family in meeting the health needs of the patient. 6) Evaluate the effectiveness of the nursing intervention through the use of outcome criteria.

II. THE PATIENT

A. Personal Data

Popoy Sese is a 23 year old male, born on February 29, 1988 in Mabalacat, eldest step son of Angelito (65 years old) , the second husband of her mother, Rosalie (55 years old), both are Filipino citizen and are Kapampangans. At present, he is living with his family at #315 apt. D 1st street Marisol Village Barangay Ninoy Aquino Angeles City. His live-in partner is Basya, a 5 months pregnant woman.

B. Socio-Economic and Cultural Factors

Popoy is able to speak 3 different languages: Kapampangan, Tagalog, and English. He affirmed that he was only able to finish 2nd year college because during those times he was influenced by his peers not to go to school rather they go somewhere else such as malls and computer shops. Popoys live in partner, Basya (20 years old), is 5 months pregnant. During their leisure time, they usually go to the mall together or play computer games and watch TV.

When it comes to his diet, Popoy usually eats tocino, hotdogs, eggs, or pancit canton every morning for breakfast which is mostly prepared by his mother or her live in partner. During lunch and dinner, they either buy cooked food in some carinderia near them or they just cook food for themselves. According to Basya, his husband is not fond of drinking water, he usually drinks softdrinks or energy drinks. She also added that Popoy does not have any vices, he does not smoke and he jsut drinks alcoholic beverages approximately once a month.

According to him, his biological parents separated when he was still young because of some confidential reasons. At present, his parents stay at home and his step father receives financial assistance from his pension which they use in their daily expenses. His step father worked abroad for more than 10 years ( he does not know the specific type of work). Currently, Popoy and Basya are both unemployed, they depend on Popoys parents for their expenses.

Unfortunately, he does not know the amount that his step father was receiving from the pension. The couple also does not know how their mother divides their income for their expenditures in the house.

Popoy is a member of the Catholic Church. Their family do not believe in herbal medicines but they believe in hilots especially if a member had some sprains or bone fractures (pilay). According to Popoy, when a family member has simple cough, colds, and fever, they usually resort in buying over-the-counter-drugs which they buy from convenience stores near them.

With regards to their environment, Basya stated that few days before Popoy had fever, the family living in front of their house also had cases of dengue. She also affirmed that they do have an open drainage infront of their house which is usually filled with dirty stagnant water and is rarely cleaned by the community people. According to Basya, the drainage was filled with trash such as plastic wrappers, plastic bags, and cups brought about by the holidays last December and January. Basya also stated that even though they know the possibilities of Dengue, they still do not comply with the protective measure to prevent it such as the use of mosquito repellents.

C. History of Past Illness

According to popoy sese he did not have any strains of dengue in the past. He stated that he did not have any serious diseases rather he usually has simple coughs and colds which he usually manage with over the counter drugs such as biogesic and neozep which they buy from convenience stores that they knew from t.v commercials. On December 30 of 2011, Popoy Sese experienced fever and flank pain. Last January 1 2012, he was brought in the ER of AMC diagnosed and treated with UTI given with home medications like antibiotic and antipyretics then was instructed to go home.

D. History of Present Illness

He stated that from January 01-04, 2012 he experienced body pain and headache accompanied by fever(38.2 C**January 03, 2012). Last January 02, 2012, he had experienced abdominal pain with a rate of 10/10 which decreased to 8/10 last January 05, 2012. He also stated that he had experienced nose bleeding as he try to clean hi nose last January 03, 2012. Three days PTA seen at ER for fever, treated as UTI. At the same time, his sister was also having a fever that is why their mother decided to bring them to Angeles Medical Center for treatment.

Last January 04, 2012, he was brought to Angeles Medical Center with a chief complaint of fever and was admitted with a diagnosis of Dengue Fever at 5:13pm.

E. Diagnostic Procedures
PROCEDURE DONE

DESCRIPTION Common blood test that evaluates the three major types of cells in the blood: red blood cells, white blood cells, and platelets. It may be ordered as part of a routine check up, or if your child is feeling more tired than usual, seems to have an infection, or has unexplained bruising or bleeding.

DATE

RESULTS

NORMAL VALUES 13. 8 17.2 g/dl

INTERPRETATION

Complete Blood Count (CBC)

Hemoglobin (Hgb) January 02, 2012 January 04, 2012 January 05, 2012 January 06, 2012 January 02, 2012 January 04, 2012 January 05, 2012 January 06, 2012 14.8 15.1 15.8 15.9 Hematocrit (Hct) 44.7 46.9 50.9 48.6 Normal

36.0% 47.0%

If hematocrit count is increasing, it suggests that capillaries are leaking and a danger sign of an increased risk of dengue shock syndrome.

January 02, 2012 January 04, 2012 January 05, 2012 January 06, 2012 January 02, 2012 January 04, 2012 January 05, 2012 January 06, 2012

Red Blood Cell (RBC) 5.07 4.20 5.40 5.26 5.48 x 1012 / L 5.46 White Blood Cell (WBC) 5.77 3.34 4.58 4.6 10.6 9.03 x 109 / L

Normal

When there are too few white blood cells, a patient's immune system is compromised, putting him or her at increased risk of all types of infection. Increase in WBC is also one of the effects of Ciprobay which ordered last January 01, 2012.

January 02, 2012 January 04, 2012

Neutrophils 64.7 61.8

40% 74% Normal

January 05, 2012 January 06, 2012 January 02, 2012 January 04, 2012 January 05, 2012 January 06, 2012 January 02, 2012 January 04, 2012 January 05, 2012 January 06, 2012 January 02, 2012 January 04, 2012 January 05, 2012 January 06, 2012 January 02, 2012 January 04, 2012 January 05, 2012 January 06, 2012 January 02, 2012 January 04, 2012 January 05, 2012 January 06, 2012 January 02, 2012 January 04, 2012 January 05, 2012 January 06, 2012

55.5 61.0 Lymphocytes 24.2 32.9 37.8 32.2 Eosinophils 0.0 2.3 1.0 1.3 Monocytes 0.3 2.4 4.0 1.9 Basophils 1.77 0.6 1.4 3.6 Platelet (Plt) 60 79 60 55 MCV (Mean corpuscular volume) 88.2 89.2 92.8 89.1

19% - 48%

Normal

0% - 7%

Normal

3% -9%

A low monocyte blood cell count increases susceptibility to infections.

0%-2%

The number of basophils in the blood can climb in someone who had infections

150 400 x 109 /L

Declining Platelet count is one of the diagnostic result which means a positive Dengue result.

82 98

Normal

January 02, 2012 January 04, 2012 January 05, 2012 January 06, 2012 January 02, 2012 January 04, 2012 January 05, 2012 January 06, 2012

MCH 29.2 28.7 28.8 29.1 MCHC 33 32.2 31.1 32.7

28 33

Normal

32 - 38

Normal

PROCEDURE DONE Blood Chemistry

DESCRIPTION The serum chemistry profile is one of the most important initial tests that is commonly performed. A blood sample is collected from the patient. The blood is then separated into a cell layer and serum layer by spinning the sample at high speeds in a machine called a centrifuge. The serum layer is drawn off and a

DATE

RESULTS Creatinine 0.93 SGPT/ALT (alanine

aminotransferase)

NORMAL VALUES 0.5 1.69 mg/dl

INTERPRETATION

January 05, 2012

Normal

January 05, 2012

143

7 56 u/l

Elevations of SGOT indicate that the liver cells are either leaky (internal contents are entering the blood) or damaged. Increase in SGPT levels is a side effects of Ciprobay a drug ordered last January 01, 2012. Normal

January 05, 2012

Sodium 139 Potassium

137 145 mmol/L

variety of compounds are then measured. These measurements aid in assessing the function of various organs and body systems.

January 05, 2012

4.1 SGOT/AST
(Aspartate aminotransferase)

3.6 5.0 mmol/L

Normal

January 05, 2012

198

5-35 u/L

AST may be used to monitor people who are taking medications that are potentially toxic to the liver. Elevations in SGOT may indicate liver damage. Increase in SGPT levels is a side effects of Ciprobay a drug ordered last January 01, 2012.

PROCEDURE DESCRIPTION DONE Special Hematological Procedure Protime Prothrombin Time is a test of the integrity of part of the clotting scheme. Partial Thromboplastin Time is often used as a starting place when investigating the cause of a bleeding or thrombotic

DATE

RESULTS

NORMAL VALUES 10 14 s

INTERPRETATION

January 04, 2012

12.8 s

Normal

APTT

January 04, 2012

50.5 s

20 40 s

it indicates decreased clotting function in the intrisic pathway.

(blood clot) episode. PROCEDURE DONE Urinalysis DESCRIPTION It is a test done to detect and measure various compounds that pass through the urine. It is done to detect early signs of disease DATE RESULTS Color: January 02, 2012 January 04, 2012 Yellow Yellow Transparency January 02, 2012 January 04, 2012 Turbid Slightly Turbid Specific Gravity January 02, 2012 January 04, 2012 1.031 1.020 Pus cells January 02, 2012 January 04, 2012 1-2 2-5 Red cells January 02, 2012 8 10 0-2/HPF A high count of red blood cells in the urine can indicate infection, trauma, tumors, or kidney stones. 0-5 HPF Normal 1.003 to 1.030 Normal Clear turbid urine suggests the presence of protein or excess cellular material. Amber ; straw yellow Normal NORMAL VALUES INTERPRETATION

January 04, 2012

1-3 Epithelial cells

Normal

January 02, 2012 January 04, 2012

Rare Rare Bacteria

Few

Normal

January 02, 2012 January 04, 2012

Few Rare

None

Bacteria in your urine can suggest infection, especially if you have other suggestive symptoms. Normal

PH January 02, 2012 January 04, 2012 5.0 6.5 Glucose January 02, 2012 tJanuary 04, 2012 Albumin January 02, 2012 January 04, 2012 +2 +1 0 If the urinary albumin levels go beyond the normal range, it is indicative of malfunctioning kidneys. (-) (-) (-) Normal 4.6 - 8

PROCEDURE DESCRIPTION DONE It refers to a series of Fecalysis laboratory tests done on fecal samples to analyze the condition of a person's digestive tract in general. Among other things, a fecalysis is performed to check for the presence of any reducing substances such as white blood cells (WBCs), sugars, or bile and signs of poor absorption as well as screen for colon cancer.

DATE

RESULTS Color: Light Brown Consistency: Soft Bacteria: Many

NORMAL VALUES brown

INTERPRETATION

January 04, 2012

Normal

January 04, 2012

Soft and bulky

Normal

January 04, 2012

none

Indicates the presence of infection.

January 04, 2012

Pus Cells: 0.3

none

Indicates the presence of infection

III. ANATOMY AND PHYSIOLOGY

BLOOD 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 a 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) Leukocytes (WBC): Description Biconcave disk, no nucleus, 78 micrometers in diameter Function Transport oxygen and carbon dioxide

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

Phagocytizes microorganism

Basophil

Releases histamine, which promotes inflammation, and heparin which prevents clot formation

Eosinophil

Spherical cell, nucleus often Releases chemical that reduce bilobed, cytoplasmic granules inflammation, attacks certain satin orange-red or bright red, worm parasites 10-12 micrometers in diameter 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 Phagocytic cell in the blood leaves the circulatory system and becomes a macrophage which phagocytises bacteria, dead cells, cell fragments, and debris within tissues Forms platelet plugs, release chemicals necessary for blood clotting

Lymphocyte

Monocyte

Platelet

Spherical or irregular cell, nucleus round or kidney or horse-shoe shaped, contain more cytoplasm than lymphocyte, 10-15 micrometers in diameter Cell fragments surrounded by a cell membrane and containing granules, 2-5 micrometers in diameter

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 threadlike protein fibers called fibrin, which traps blood cells, platelets and fluids. 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. 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. 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.

IV. PATHOPHYSIOLOGY Client based

Poor environmental condition Poor health practices Geographical areas tropical islands in the Pacific Living in urban areas

Presence of open drainage filled with dirty stagnant water in front of their house

Popoy is not using any protective measure against mosquito

Increase incidence of mosquito breeding

Aedes Aegypti (carrier) Bite from mosquito (portal of entry is the skin) Dengue Virus enters the body Carried by circulation and multiplies Dengue virus replicates within the cells & antibodies attach to viral antigens Platelet destruction Interferons are released Thrombocytopenia Release of cytokines, urokinase, prostaglandin, platelet activating factors which stimulates WBC and pyrogen release Dengue Virus suppresses marrow production of platelets Redness and itchiness

60 Jan. 02, 2012 79 Jan. 04, 2012 60 Jan. 05, 2012 55 Jan. 06, 2012

Body pain January 0104, 2012

Fever January 0104, 2012 38.2 C**January 03, 2012

Head ache January 01-04, 2012

Increased capillary fragility

Decreased blood coagulation bleeding

Nasal mucosa Epistaxis January 03, 2012

GIT tract Bleeding and ulceration

Abdominal pain January 02, 2012

Dengue fever is a disease caused by one of a number of viruses that are carried by mosquitoes. These mosquitoes then transmit the virus to humans. Dengue fever can occur when a mosquito carrying the arbovirus or flavivirus bites a human, passing the virus on to the new host. Once in the body, the virus travels to various glands where it multiplies. The virus can then enter the bloodstream. The presence of the virus within the blood vessels, especially those feeding the skin, causes changes to these blood vessels. The vessels swell and leak. The spleen and lymph nodes become enlarged, and patches of liver tissue die. A process called disseminated intravascular coagulation (DIC) occurs, where chemicals responsible for clotting are used up and lead to a risk of severe bleeding (hemorrhage). After the virus has been transmitted to the human host, a period of incubation occurs. During this time (lasting about five to eight days) the virus multiplies. Symptoms of the disease appear suddenly and include high fever, chills, headache, eye pain, red eyes, enlarged lymph nodes, a red flush to the face, lower back pain, extreme weakness, and severe aches in the legs and joints. Precipitating and Predisposing factors of the disease includes; poor environmental condition specifically having an open drainage full of dirty stagnant water in front of the clients house, poor health practices especially if the client does not use any protective measure, also the geographical location is a big factor especially to our archipelago which happen to be a tropical country which is a good breeding site for vectors like mosquitos, predisposing the client to acquire the disease.

PATIENT AND HIS CARE A. Medical management 1. Drug study NAME OF DRUG DOSAGE, FREQUENCY, & ROUTE Dosage: 500 mg 1 tab GENERAL ACTION Anti-pyretic INDICATION SIDE EFFECTS NURSING CONSIDERATION - Take the temperature prior to administrations and record the initial reading.

Brand name: Biogesic

- Temporary reduction of fever - Temporary relief of minor aches and pains

- Paracetamol Hepatotoxicity

Generic name: paracetamol

Frequency: Q4 PRN

Stock dose: 500 mg

Route: oral

- Take the temperature directly after 30 mins- 1 hour after administration and record the result.

Brand name: Ciprobay XR

Generic name: ciprofloxacin

Computation: (500mg/500mg) x 1 tab = 1 tab Fluoroquinolone, -Treatment of Dosage: 500 mg 1 tab Antibiotic uncomplicated UTIs caused by Escherichia Coli Frequency: OD

- Renal, Cardio, CNS, Tendon, hepatic toxicity (Flouroquinolone Toxicity) - Decrease in WBC

- Encourage patient to drink plenty of fluids while taking this drug since it may cause renal failure and possibilities of diarrhea and vomiting. - Encourage patient to take small frequent meals if vomiting occurs.

Stock dose: 500 mg

Route: oral

Computation: (500mg/500mg) x 1 tab = 1 tab

- Encourage patient to use caution in moving because this drug may cause blurring of vision and dizziness. Hepatic protector - Dietary supplement to support liver function - Protect the liver from viral, alcoholic, drug induced liver damage - Reduced Appetite - Inform patient that gastrointestinal pain after - Nausea administration is a normal side effect - Abdominal Pain - Take with food - GI bleeding - Increase Fluid Intake - Diarrhea - Encourage small frequent feeding since it may cause nausea and vomiting

Brand name: Livolin Forte XR

Dosage: 1 cap 500 mg

Generic name: Phosphatidylcholine 300 mg, nicotinamide 30 mg, dl-alpha tocopheryl acetate 10 mg, vit B1 10 mg, vit B2 6 mg, vit B6 10 mg, vit B12 10 mcg

Frequency: TID

Route: Oral

Computation: (500mg/500mg) x 1 tab = 1 tab

Stock dose: 500 mg

2. IVF IVF GENERAL DESCRIPTION INDICATION for fluid and electrolyte replenishment and caloric supply in a single dose container for intravenous administration COMPUTATIONS Order: 160cc/hour Time to consume: (1000ml/160cc)= 6.25 hours gtts/min: (1000ml x 15 gtts/min) / (6.25 hours x 60 minutes) = 15000/375 = 40gtts/min D5NSS Normal Saline (1 Bottle Solution in 5% Consumed) Dextrose is a hypertonic solution It can be used for the temporary treatment of shock if plasma expanders are not available Order: 160cc/hour Time to consume: (1000ml/160cc)= 6.25 hours gtts/min: (1000ml x 15 gtts/min) / (6.25 hours x 60 minutes) = 15000/375 DATE ORDERED Date ordered: January 04, 2012 NURSING RESPONSIBILITIES BEFORE,DURING, AND AFTER 1. Check doctors order 2. Explain procedure to the client 3. Tell the patients that she might feel a discomfort from the tourniquet and IV insertion 4. Check and monitor IVF regulation and level of fluid 5. Check if there is a need for removal and replacement of fluid 6. Check if the tube is in the vein and signs of edema 7. Check if there is a backflow of blood 8. Check if there is bubbles present in the tube 9. Always monitor vital signs

D5LRS Lactated Ringer's (4 Bottles Solution in 5% Consumed) Dextrose is a sterile and an isotonic nonpyrogenic solution

Date performed: January 04, 2012

Date ordered: January 05, 2012

Date performed: January 05, 2012

= 40gtts/min PLRS Plain Lactated (1 Bottle Ringers Solution is Consumed) a classical isotonic, balanced electrolyte solution with major electrolytes in the same concentration as in blood. Contains sodium, potassium, calcium, chloride, and bicarbonate as lactate. Used for fluid Order: resuscitation after a 160cc/hour blood loss due to trauma, surgery, or a burn injury. Time to consume: (1000ml/160cc)= 6.25 hours gtts/min: (1000ml x 15 gtts/min) / (6.25 hours x 60 minutes) = 15000/375 = 40gtts/min The solution is administered by intravenous infusion for parenteral maintenance of routine daily fluid and electrolyte requirements with minimal carbohydrate calories. Order: 160cc/hour Time to consume: (1000ml/160cc)= 6.25 hours gtts/min: (1000ml x 15 gtts/min) / (6.25 hours x 60 minutes) = 15000/375 = 40gtts/min Date performed: January 06, 2012 Date ordered: January 06, 2012

Date performed: January 06, 2012

D5NM Normosol-M and (1 Bottle 5% Dextrose is a Consumed) sterile, nonpyrogenic, hypertonic solution of balanced maintenance electrolytes and 5% dextrose injection in water for injection.

Date ordered: January 06, 2012

3. Diet DIET DAT except dark colored foods GENERAL DESCRIPTION Client can eat foods and drink fluid as tolerated except dark colored food and drinks. Ex. Soft drinks, fruit juices such as cranberry, grapes, and strawberry. INDICATION It is indicated for patients with dengue so that in the laboratory results, dark outputs would not be mistaken as blood. DATE ORDERED January 04, 2012 NURSING RESPONSIBILITIES BEFORE,DURING, AND AFTER Before: Verify doctors order During: Explain the details of the diet to the patient and to the SO Encourage patient to eat nutritious foods he can tolerate. Position the client to fowlers position. Instruct the client not to take in any foods or fluids while lying down. After: Document patients response to the diet. 4. Exercise

Popoy spends his time in the hospital lying on bed and sometimes he was seen sitting on bed while having some conversations with her wife, Basya. . During the first interaction, he was seen resting due to the abdominal pain he have. During the nurses rounds he was also seen playing with his gadgets most of the time.

B. NCP 1. CUES S>

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION Platelet count: 60 Thrombocytopenia (thrombocythemia) is a blood disorder characterized by an abnormally low number of circulating platelets (thr ombocytes) in the bloodstream. Because platelets play an important role in the process of coagulation (blood cl otting) and in the plugging of damaged blood vessels, persons with decreased platelets bruise easily and can have episodes of excessive bleeding (hemorrhage).

OBJECTIV ES

NURSING INTERVENTIONS > Provide information regarding the condition that may result in risk for bleeding > Monitor pulse, Blood pressure

RATIONALE > to promote awareness

EVALUATION

Risk for bleeding related to

O>

altered clotting factor

After 2 hours of nursing interventio ns, There will be identificati on of behaviors that reduces the risk for bleeding.

> An increase in pulse with decreased Blood pressure can indicate loss of circulating blood volume and may point out to bleeding.

> Check on patient at least every 2 hours > Assist patient with transfer/ambulation

> his is a primary preventive measure to ensure patient safety > to aid in preventing from tripping off on the floor or from the bed.

> Encourage use of soft toothbrush, avoiding straining for stool, and forceful nose blowing. > Emphasize the importance of safety

> Minimizes damage to tissues, reducing risk for bleeding > This promotes education and increases the

measures CUES NURSING DIAGNOS IS S>Mas Acute pain akit pa yung chan ko pero hindi na tulad nung nakaraa ng araw na sobra talaga yung sakiit O>facia l grimace Pain scale of 8/10 Pain impulses join central nervous system (CNS) fibers in the dorsal horn of the spinal cord. Here the impulses are projected upward to the brain, and the brain will interpret it as pain. After 30 minutes of nursing interventio n, the painscale will decrease from 8/10 to 5/10 >Encourage diversional activities Such as playing gadgets > repositioning to the comfortable position >Encourage to have adequate rest periods SCIENTIFIC EXPLANATION OBJECTI VES NURSING INTERVENTIONS

awareness of the client on the condition. RATIONALE

EVALUA TION

> To promote pain management

>To alleviate pain

>To distract attention and reduce tension

CUES S>Hindi ako nakatulog kagabi kasi laging pumapasok yung nurse tsaka masakit pa pakiramdam ko

NURSING DIAGNOSIS Sleep deprivation related to interruptions

SCIENTIFIC EXPLANATION The patients are always subjected to some procedures, such as VS

OBJECTIVES After 2 hours of nursing intervention, appropriate interventions to

NURSING INTERVENTIONS >Minimize entering to the room specially at night

RATIONALE >To reduce stimulation and promote sleep

EVALUATION

for therapeutic monitoring, regimen

>Provide adequate rest.

>Prolonged physical and mental activity without overstimulation promotes sleep

laboratory measures promote sleep and also checking the patency of the IV fluid. With these actions, it is therefore related for having a will be identified.

>Provide calm, quiet >To promote environment. adequate sleep and rest periods.

O>slowed reaction

disturbance of sleep pattern. Since an ill person has a

>easily awakened during rounds

very sensitive sensorium,he/she can be awakened due to the above reason.

C. Discharge Plan Objectives Content Outline Methods of Instruction Time Allotted (mins) Methods of Evaluation

After 30 minutes of health teaching, the patient will be able to:

1. Identify the different medications Together with their route, dosage, frequency, and indications.

Paracetamol 500 mg 1 tab/Q4 PRN Ciprobay XR 500mg tab/ OD Livolin Forte 1 cap TID

One on one discussion

10

Question and answer

Question and answer 2. Verbalize ways on how to prevent bleeding. Advise to use electric razor Encourage the use of soft bristled toothbrush Instruct SO to move the sharp objects away from the patient Confirm that any food may be eaten except dark colored foods such as softdrinks, dinuguan, and others. One on one discussion 10

3. State the right diet One on one discussion Question and answer 10

VI. LEARNING DERIVED In making this case study I was able to learn that time management and being organized really play a big role for easier and faster accomplishment of tasks. As Im in the process of gathering data and information, I had a hard time in organizing the things that needed to be asked and I only have a short time to interview the patient since I still have to do the duties and responsibilities of a medication nurse. As a result the data that we have gathered were not sufficient for my case study to be comprehensive enough. I think for the next time we will be doing our case study proper distribution of tasks must be done prior to the actual gathering of data so that guide questions would be done before the interview process. ----Kathleen Sicat In this case study, my group mates and I were somewhat disorganized and unprepared. For one, we didnt even decide what case study to use until the day before the Oral Defense. None of us reviewed the first case study that we intended to use and we ended up changing cases in the end. It was hectic, but we were able to pull it off and accomplish our goal. Although we had some trouble at first, I did end up learning a lot, both medical and moral. For medical, I gained a deeper understanding of dengue stage 1 and its disease process. I suppose for me, the moral lesson of this situation is to always verify and double check anything that we are not absolutely sure of. This is important for school work as I learned today, but it can also mean the difference between the life and death of our patients. Knowledge of the task at hand is imperative to its efficient and effective implementation. ---Nico Sese

A case study is a requirement which all nursing students must complete in order to gain the appropriate knowledge, skills, and attitude in the field of nursing. It allows the students to delve into the synthesis and meaning of the disease, the signs and symptoms, as well as the corresponding nursing care management for the case. Students are given the opportunity to learn beyond what clients may feel and into the different dimensions of the disease. In short, the case is not limited to merely the treatments of the patient to his or her signs and symptoms. In the time it took to complete this case study, it can be said that I have really learned alot about dengue. It has also beneficial on the part of the group because the case served as a review on previous lessons discussed in previous NCM classes. In completing this case, however, I encountered many difficulties and one such difficulty was the creation of the pathophysiology and the feeling of being limited by time. Although it remains true that his case study was difficult to accomplish due to a lack of skills in the creation of a case study, still, many learnings regarding the case have been derived. Despite the sleepless night sacrificed to complete the case study, the efforts in the end have paid off. Even though the case had been done in such a busy and turbulent time (U-days), still this work serves as proof that with the belief and faith in God and ones own ability to accomplish goals, all things are possible. --- Joel Maniulit

Through this study, I learned the pathophysiology of Dengue. How the microorganism causes dengue and how it affects the body. This information may help me in giving health teachings to future patients with dengue that I may handle. We, student nurses, may have not prevented a disease from occurring in our patient but we can prevent other possible complications to happen and make the condition worsen. We can also help others how to prevent the occurrence of the disease. In completing this study, I learned that patience is very important will help in finishing this study faster. ---Clarenz Laxamana In doing this partial requirement as a nursing student, I have learned many new techniques by the help of our instructor which may help us a lot in doing and interacting with clients. I am being competent and tacful in doing my responsibilities as a nurse. In these disease , I appreciate more on the management on how to prevent and treat the disease. Through this case I was able to broaden my knowledge regarding the disease process and the different medications which may help in treating the signs and symptoms brought by the disease. ---Cutillion, Ar-j

In doing this case study, I have learned the definition of dengue and the several predisposing and precipitating factors which may lead to its effects such as head ache, body malaise, and bleeding. I have learned the different medications together with their effects and general action. Ive also learned the significance of conducting the different laboratory procedures in monitoring the condition of a dengue patient. --- Francis Victoriano Ive learned a lot during this rotation. From the simplest techniques on how to interact with the patient on how to read and understand charts. On how to change and remove Intravenous Fluid .To carry out doctors order with my clinical instructor or staff nurses. Detailed ways on how to prepare and administer IV medications. Especially Ive learned to care with my whole heart for these patients in need. Of course there will not be a good outcome if there are no difficulties be experienced. Like trying to understand the Doctors order. Sometimes computing for the medications. Establishing rapport with patients significant others and to the staffs. This thinks are the normal process for a person who is just on the starting point. We must accept our mistakes and as they say this will be our guides in the future. --- Ruffa Cabatbat

Through this case study, I have learned the different signs and symptoms that may be present in a person with Dengue fever. I have learned how to be responsible with the task being assigned to me. In our situation, I have also learned the importance of time management since we only have a little time to complete our individual and group case study which are accompanied by other requirements in our other subjects. ---Jeremy Marcos

VII. REFERENCES (http://www.who.int/mediacentre/factsheets/fs117/en/, retrieved January 12, 2012) (http://in.answers.yahoo.com/question/index?qid=20091015004748AAx7pGy, retrieved January 12, 2012) (http://www.brighthub.com/science/medical/articles/30891.aspx, retrieved January 15, 2012) (http://www.hopkinslupus.org/lupus-tests/screening-laboratory-tests/urinalysis/, retrieved January 15, 2012) (http://hemoglobincount.net/, retrieved January 15, 2012) (http://www.oasisdesign.net/health/dengue.htm, January 15, 2012) (http://www.ehow.com/about_5606257_signs-monocytes-blood-cell-count.html, retrieved January 15, 2012) (http://www.wisegeek.com/what-are-basophils.htm, retrieved January 15, 2012) (http://kidshealth.org/parent/system/medical/test_alt.html, retrieved January 12, 2012) (http://labtestsonline.org/understanding/analytes/alt/tab/test, retrieved January 12, 2012) (http://www.labtestsonline.org.uk/understanding/analytes/aptt/tab/test, retrieved January 15, 2012) (http://wiki.answers.com/Q/Normal_values_in_fecalysis, retrieved January 12, 2012) (http://texasheart.org/HIC/Anatomy/, retrieved January 17, 2011)