205 cs -dengue fever

8/3/2019 205 CS -Dengue Fever

http://slidepdf.com/reader/full/205-cs-dengue-fever 1/39

Liceo de Cagayan University

R.N. Pelaez Blvd.

Carmen, Cagayan de Oro CityCollege of Nursing

Submitted to:

Mrs. Franelee Zulueta , RN, MN

Submitted by:

GROUP 15

Ortega, Ailyn Joy

Pacapac, Kathleen Love

Padeño, Mercy

Pamabusao, Irish Bette

Pegalan Jenny

Penados, Aiko Louigie

Ramos, Randy

Roque, Mhay Ricamare

Rosales, Kristine Ellen

Sazon, Gian Carlo

Seriña, Roy Jr.

Tan, Jessamine Grace

Tan, Marielle Mae

Villamor, Winberly Fatima

Zornosa, Maria Socorro

December 10, 2009



I. INTRODUCTION

A. OVERVIEW OF THE STUDY

Dengue fever is an infectious disease carried by mosquitoes and caused by any one of

the of four dengue viruses. You can get it if an infected mosquito bites you. This disease used

to be called "break-bone" fever because it sometimes causes severe joint and muscle pain that

feels like bones are breaking, hence the name. Health experts have known about dengue fever

for more than 200 years. It occurs in tropical and sub-tropical areas of the world. Symptoms

appear 3—14 days after the infective bite. Dengue fever is a febrile illness that affects infants,

young children and adults.

Symptoms include a high fever, headaches, joint and muscle pain, vomiting and a rash.

Most people with dengue recover within 2 weeks. Until then, drinking lots of fluids, resting and

taking non-aspirin fever-reducing medicines might help. It is important to maintain hydration.

Sometimes dengue turns into dengue hemorrhagic fever, which causes bleeding from your

nose, gums or under your skin. It can also become dengue shock syndrome, which causes

massive bleeding and shock. These forms of dengue are life-threatening.

Dengue viruses are transmitted to humans through the bites of infective female Aedes

mosquitoes. Mosquitoes generally acquire the virus while feeding on the blood of an infected

person. After virus incubation for eight to 10 days, an infected mosquito is capable, during

probing and blood feeding, of transmitting the virus for the rest of its life. Infected female

mosquitoes may also transmit the virus to their offspring by transovarial (via the eggs)

transmission, but the role of this in sustaining transmission of the virus to humans has not yet

been defined. Infected humans are the main carriers and multipliers of the virus, serving as a

source of the virus for uninfected mosquitoes. The virus circulates in the blood of infected

humans for two to seven days, at approximately the same time that they have a fever; Aedesmosquitoes may acquire the virus when they feed on an individual during this period.



The mosquito flourishes during rainy seasons but can breed in water-filled flower pots,

plastic bags, and cans year-round. One mosquito bite can inflict the disease.The virus is not

contagious and cannot be spread directly from person to person. There must be a person-to-

mosquito-to-another-person pathway

Worldwide, 50 to 100 million cases of dengue infection occur each year. This includes

100 to 200 cases in the United States, mostly in people who have recently traveled abroad.

During the last part of the 20th century, many tropical regions of the world saw an increase in

dengue cases. Epidemics also occurred more frequently and with more severity. In addition to

typical dengue, dengue hemorrhagic fever (DHF) and dengue shock syndrome also have

increased in many parts of the world. Globally, there are an estimated several hundred

thousand cases of DHF per year. According to the World Health Organization, there are an

estimated 50 million cases of dengue fever with 500,000 cases of dengue hemorrhagic fever

requiring hospitalization each year. Nearly 40% of the world's population lives in an area

endemic with dengue.

B. OBJECTIVE OF THE STUDY

The study was conducted to determine and identify health problems of the patient to

implement nursing interventions that would alleviate her present condition. And thus, be able to

impart health teachings in promoting health and prevention of illness; be able to relate

applicable recommendations which include referrals and follow-up to intervene on the

problems that are being identified and be able to encourage participation on the promotion of

health and wellness.

C. SCOPE AND LIMITATIONS

This study will act as a baseline data as well as guide for coming up with a good,

reliable, accurate and comprehensive research paper dealing with issues commonly

experienced by patients in the hospital setting. The study focused on one patient admitted at

SABAL HOSPITAL. The time frame of this study begins from the physical assessment last



November 18, 2009 and on the first day of duty last November 19, 2009 up to the 2nd day of

exposure November 20, 2009 11-7 shift at Semi-Private Ward, room 401, Station 2.

Subjective data gathered were taken from the patient alone. The activities include collecting,

organizing, validating and recording any data from the chart, significant others and from our

observation, which will be enough to support our study. We had also identified actual problems

manifested by the patient and implemented nursing intervention. Furthermore, we had also

imparted health teachings that will be beneficial in the promotion of patient’s health. This study

does not involve providing financial assistance or giving false reassurance to the patient as

well as their significant others.



II. A. PATIENT’S PROFILE

Name: D.L

Home Address: Kauswagan, CDO

Sex: Female

Age: 15 years old

Religion: Roman Catholic

Civil status: Single

Education level: 4th year high school

Nationality: Filipino

Date admitted: November 18, 2009

Time: 12:21 am

Attending physician: Dr. Sabal

Chief complaint: Fever, Abdominal pain and headache

Admitting diagnosis: Dengue fever

BP: 110/90 mmHg

Pulse rate: 89 bpm

Respiratory rate: 26 cpm

Temperature: 38.7 cHeight: 5’3

Weight: 58.9 kg

B. HISTORY OF PRESENT ILLNESS

Patient D.L 15 years old, a 4th year high school student, who has a history of asthma

and allergic to pollen grains and dust was admitted on Sabal Hospital last November 18, 2009

at 12:21 am with a chief complaint of abdominal and headache.

Prior to admission patient had a fever after being exposed to the rain. She took Biogesic

to relieve her fever but it remained unrelieved so she was brought to the hospital. Upon

admission patient complained of abdominal pain and headache.



III. DEVELOPMENTAL DATA

1. ROBERT HAVIGHURST: DEVELOPMENTAL TASK THEORY

In this theory, the patient belongs to the Adolescence. During this age the patient

undergoes the following changes:

A. Achieving new and more mature relations with age- mates of both sexes.

B. Achieving a feminine/ masculine role.

C. Accepting one’s physique and using the body effectively.

D. Achieving emotional independence from parents and other adults.

This explains why the patient seems to give much importance in beautifying self

because this is the time where a person is conscious of the biological changes that take

place in adolescence. We can relate these developmental tasks to patient D. L because

she’s 15 years old and at the time of our care to her, she makes it a point that she’s

neat and clean every time we visit her. She was a bit shy especially when it comes to

performing procedures related to her plan of care.

2. ERIK ERIKSON: EIGHT STAGES OF DEVELOPMENT

In this theory, patient belongs to the Adolescence stage which can be classified

from 12- 20 years old. The Central Task in this stage is Identity versus role confusion.

The indicators of positive resolution are coherent sense of self and plan to actualize

one’s abilities. The indicators of Negative resolution are feelings of confusion,

indecisiveness, and possible antisocial behavior.

To evaluate our patient using this theory, she may fall under the one’s who

manifests positive indicators resolutions. Although our patient may not be that

consistent and active when it comes to conversation, you can very well see that she is



trying to slowly share, that she has plenty of friends in school and that they have similar

likes and dislikes that enabled them to create a bond. Patient D. L was like a typical

teenager that gave importance to her social life and studies. We observed that she

was concerned about her studies because even though she was admitted at the

hospital, she was worried about her absences that could possibly pull down her grades.

Erikson does not believe that the proper solution to a stage crisis is always

completely positive. Some exposure or commitment to the negative end of the person’s

bipolar conflict is sometimes inevitable- you cannot trust all people under all

circumstances and survive, for example. Nonetheless, in the healthy solution to a stage

crisis, the positive resolution dominates

3. SIGMUND FREUD: PSYCHOSEXUAL THEORY OF DEVELOPMENT

Genital stage is the last stage in this theory, this occurs from puberty the after.

Energy is directed towards full sexual maturity and function and development of skills

needed to cope with the environment. This stage implies Encourage separation from

parents, achievement of independence, and decision making.

4. PIAGET’S COGNITIVE DEVELOPMENT

Cognitive Development refers to the manner in which people learn to think,

reason, and use language. It involves a person’s intelligence, perceptual ability, ability

to process information. Cognitive development represents a progression of mental

abilities from illogical to logical thinking, from simple to complex problem solving, and

from understanding concrete ideas to understanding abstract concepts.

According to Piaget (1966), Cognitive development is an orderly. Sequential

process in which a variety of new experiences must exist before intellectual abilities can

develop. Piaget’s phase of cognitive development ends with formal operation phase.

http://www.essortment.com/all/psychosocialdev_rijk.htm

http://www.essortment.com/all/psychosocialdev_rijk.htm



In Patient D. L’s age which belongs to the formal operations phase, there is use

of rational thinking and reasoning is deductive and futuristic.

This theory can be used in developing teaching strategies like in the case of

patient D.L, she is 15 years old and can be expected to use rational thinking and to

reason; therefore when explaining the need for a medication, we can outlined the

consequences of taking and not taking the medications that enabled our patient to make

a rational decision.



IV. DIAGNOSTIC EXAM

Diagnostic Exam Result Normal Values Significance of the Result

Nov. 17, ‘09

CBCHgb

WBC

Monocytes

Nov. 18, ‘09

CBCHgb

Platelet

Monocytes

Urinalysis

Microscopic

Sp Gravity

Sugar

Pus cell

Epithelial

Albumin

12:05 AM

HematologyPlatelet count

0.36

2.11

0.41

0.36

140

0.14

Yellow

1.015

( - )

3.5

None

( - )

100,000/mm3

0.37- 0.47

3.8- 10.8

00- 0.10

0.37- 0.47

150- 400

00- 0.10

Yellow

1.010-1.025

( - )

0-2

None

( - )

150,000-350,000/mm3

- Anemia, dec. 02capacity of theblood

- Infection- Fever

- Increased withviral infection

- Anemia, dec. 02capacity of theblood

- Dengue fever

- Increased withviral infection

- Normal

- Normal

- Normal

- Presence of bacterial infection

- Normal

- Normal

- Decreasingplatelet countsignifies possible



Platelet count


Nov. 19,’0912:05am


Nov. 20,’096:11am


Platelet count

62,000/mm3

68,000/mm3

100,00/mm3

114,000/mm3

68,0000/mm3

150,000-350,000/mm3

150,000-350,000/mm3

150,000-350,000/mm3

150,000-350,000/mm3

150,000-350,000/mm3

bleeding


bleeding

- Decreasingplatelet countsignifies possiblebleeding


bleeding

- Decreasingplatelet countsignifies possiblebleeding

- Decreasingplatelet count

signifies possiblebleeding



Date Ordered I.V Fluids Clinical significance

Nov. 19, 0912:05 Am

Nov. 19,’09

Nov. 19,’093:00 pm

Nov. 20,’093:30 am

Nov. 20,’0910:45 am

Nov. 20,’095:00 pm

Nov. 20.’09

#5 D5LR 1 L @ 40gtts/min







To replenish fluid andelectrolyte in the bodyand for administration of

IVTT meds

To replenish fluid andelectrolyte in the bodyand for administration of IVTT meds








V. A. ANATOMY AND PHYSIOLOGY



B. PATHOPHYSIOLOGY

Dengue Fever Definiton: Is a disease caused by a family of viruses that are transmitted by mosquitoes.

Predisposing factors: Precipitating factors:Gender both SanitationEnvironmental

DENGUE FEVER

↓Causative agent: DENGUE VIRUS TYPES 1,2,3,4

Chikungunya virus↓

INCUBATION PERIOD: 6 days to one week↓SOURCE OF INFECTION :

1. the Aedes Aegypti/ household mosquito2. the infected person.

3 CLASSIFICATIONSMILD MODERATE SEVERE, FRANK

► w/ slight fever w/ high fever w/ flushing

►w/ or without less hemorrhage sudden high fever

► petechial hemorrhage no shock severe hemorrhagesudden drop of temp

shock , death

CLINICAL MANIFESTATIONS:

1st 4 days 4th- 7th days 7th-10th daysFebrile / invasive toxic or hemorrhagic stage Convalescent/ recovery stag

► ↑temp lowering of temp generalized flushing

► Headache severe abdominal pain w/ interventing areas of blanching

► later flushing freq bleeding of GIT appetite regained and BPalready stable



► vomiting hematemesis or melena► epistaxis unstable BP► conjunctival infection narrow pulse pressure► Shock

DIAGNOSTIC TESTTourniquet test (rumple-lead test)

MEDICAL MGT:1. Paracetamol for fever, analgesic for headache, does not give aspirin for shock.2. Fluid replacement3. ORESOL

NURSING MGT:1. Tourniquet test

2. Position patient on dorsal recumbent for shock3. Elevate position for hemorrhage4. DIET: low fat, low fiber, non irritating , non carbonated



VI. DOCTOR’S ORDER

DATE/TIME DOCTOR’S ORDER RATIONALE OF ORDER

11-18-09/12:30 am

11-18-09/6:00 am

11-19-09/12:05 am

Please admit under thecare of Dr. Sabal

Problem: Fever Temperature: every 4 hrs.

No chocolate colored foods

Venoclysis with D5LR @ 40gtts/min

CBC taken @ OPDU/ARepeat CBC @ 6am

Meds: omeprazole 40 mgIVTT now

PCM 500 mg tabevery 4 hrs. >37.8 degreeCelsius

I and O every shift

Monitor V/S every 2 hrs.

Relay labs. To AP

Refer unusualities

IVF TF with D5LR @ SD

For chest xray PA

Isoprinosine 500mg BIDRanitidine 150 mg BID

Fern-C BID

Repeat platelet count exam

For observation andtreatment

To closely monitor temp. for any increase or decrease.

To identify if there is bloodin the stool.

To start administration of IVand meds.

To determine if platelet iswithin normal value.To relieve epigastric pain

To relieve fever

To determine fluid and

electrolytes balance.

To inform AP on lab resultsfor evaluation.To indicate deviation fromnormal and noteimmediately.To follow up electrolytesand avoid imbalances.To determine if lungs arenormal.To treat viral infectionTo neutralize acid in thestomach.To boost immune system.

To monitor platelet count



3:00 pm

11:00 pm

11-20-09/7:00 am

3:00 pm

11:00 pm

TF D5LR 1L @ 40 gtts/min

No new doctors order

No new order’s order




increase or decrease.To maintain fluid andelectrolyte supplementsTo consider continuation of therapy

To consider continuation of therapyTo consider continuation of therapyTo consider continuation of therapyTo consider continuation of therapy



VII. NURSING SYSTEM REVIEW CHARTName: D. L. Date: November 18,2009PR:89 bpm BP: 110/90 mmHg Temp: 38.9 C RR: 26 cpm Weight: 58.9 kg.

EENT:[ ] impaired vision [ ] blind

[ ] pain [ ] reddened [ ] drainage[ ] gums [ ] hard of hearing [ ] deaf Pale conjunctiva[ ] burning [ ] edema [ ] lesion [ ] teeth Pale mucousAssess eyes, ears, nose, membranethroat for abnormality [x ] No problem Productive coughRESP: Dry lips[ ] asymmetric [ ] tachypnea Body Temp: 38.9 C[ ] apnea [ ] rales [ ] cough [ ] barrel chest Poor appetite[ ] bradypnea [ ] shallow [ ] rhonchi Epigastric pain[x] sputum [ ] diminished [ ] dyspnea Dry and pale skin[ ] orthopnea [ ] labored [ ] wheezing Hot skin[ ] pain [ ] cyanotic IVFAssess resp. rate, rhythm, depth, pattern,

breath sounds, comfort [ ] no problemCARDIOVASCULAR:[ ] arrhythmia [ ] tachycardia [ ] numbness[ ] diminished pulses [ ] edema [ ] fatigue[ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [x] painAssess heart sounds, rate rhythm, pulse, bloodPressure, circ., fluid retention, comfort[ ] no problemGASTROINTESTINAL TRACT:[ ] obese [ ] distention [ ] mass[ ] dysphagia [ ] rigidty [x ] painAssess abdomen, bowel habits, swallowing, Body weaknessBowel sounds, comfort [ ] no problemGENITO – URINARY AND GYNE: Limited ROM[ ] pain [ ] urine color [ ] vaginal bleeding[ ] hematuria [ ] discharge [ ] noctoriaAssess urine freq., control, color, odor,Comfort / Gyn-bleeding, discharge[x] No problemNEURO:[ ] paralysis [ ] stuporous [ ] unsteady Infiltrated site[ ] seizure [ ] lethargic [ ] comatose [ ] vertigo[ ] tremors [ ] confused [ ] vision [ ] gripAssess motor function, sensation, LOC, strengthGrip, gait, coordination, orientation, speech[x] no problem

MUSCULOSKELETAL and SKIN:[ ] appliance [ ] stiffness [ ] itching [ ] petechie[x] hot [ ] drainage [ ] prosthesis [ ] swelling[ ] lesion [x ] poor turgor [ ] cool [ ] deformity[ ] wound [ ] rash [ ] skin color [ x] flushed[ ] atrophy [ ] pain [ ] ecchymosis[ ] diaphoretic [ ] MoistAssess mobility, motion gait, alignment, joint function/Skin color, texture, turgor, integrity [ ] no problem



VIII. NURSING ASSESSMENT ll

SUBJECTIVE OBJECTIVECOMMUNICATION[ ]hearing loss Comments[ ]visual changes “wala man koy problema sa

akong pananaw og pandungog”as verbalized by the pt.

[ x ]denied

[ ] Glasses [ ] languages[ ] Contract lens [ ] hearing aide

R LPupil size: 3mm both eyes [ ]speechdifficultiesReaction: (PERRLA) Pupil is Equally Round

Reacted to Light Accommodation

OXYGENATION[ ] Dyspnea Comments[ ] Smoking history “ inig mu-ubo ko kay nay

mugawas na green na plema”as verbalized by the pt.

[x] Cough[x] Sputum[ ] Denied

Resp. [ x ] Regular [ ] Irregular Describe: Pt’s respiratory rate is withinnormal range – 26cpm

R – Right lung is symmetrical to left lung

L – Left lung is symmetrical to right lung

CIRCULATION[ ] Chest pain Comments[ ]Leg pain “okay raman ako pag-ginhawa

Wala man pod ko galisod” asVerbalized by the pt.

[ ]Numbness of Extremities

[x]Denied

Heart Rhythm [ x ] regular [ ] irregular Ankle Edema:

Pulse Car. Rad. AP Fem*R + + +L + + + +Comments: all pulse are palpable*If applicable

NUTRITIONDiet: DAT. No chocolate colored foods[ ]N [ ]V Comments

“gakawalaan ko gana mukaon”As verbalized by the pt.

Character [ x ] Recent change in

Wt., appetite[ ] Swallowing

Difficulty[ ] Denied

[ ] Dentures [ x ] none

Full Partial withpatient

Upper : [ ] [ ] [ ]

Lower: [ ] [ ] [ ]

ELIMINATIONUsual bowel pattern [ ] Urinary Frequency

1 x a day 4 x a day[ ] Constipation [ ] urgency

Remedy [ ] dysuria [ ] Hematuria

CommentsPt. is unable to recall

Bowel sound: Hypoactive sounds 2 mins.

Abdominal Distention



Date of last BM [ ] incontinencenot recalled [ ] Polyuria

[ ] Diarrhea [ ] foly in placeCharacter [ ] Denied

Present [ ] yes [ x ] noUrine* (color,consistency, odor)

yellow colored urine,aromatic odor and moderate amount

MGT. of health & Illness:[ ] Alcohol [ ] Denied(amount, frequency)Pt. has no history of any alcoholic events beingtake place.[ ] SBE last Pap Smear:LMP: not recalled

Not undergone papsmear and SBE

Briefly describe the patient’s ability tofollow treatments ( diet, medication, etc.)from chronic health problems ( if present)

Pt. is cooperative on followingtreatment.

SKIN INTEGRITY

[ x ] Dry Comments[ ] Itching “lain lage ako pamit kau gauga

Og luspad” as verbalized by the pt.[ ]Other [ ]Denied

[ x ] Dry [ ] cold [ ] pale[ ] Flushed [ x ] warm[ ] Moist [ ] cyanotic

*rashes, ulcers, decubitus ( describe size,location, drainage) : Dry skin is beingnoted

ACTIITY/SAFETY[ ] Convulsion Comments[ ] Dizziness “makalakaw man ko pero

Kinahanglan naa koy kauban”As verbalized by the pt.[ x ] Limited motion

of joints

Limitation inAbility to

[ x ] Ambulate[ ] Bathe self [ ] Other [ ] Denied

[ ] LOC and orientation: pt. is oriented todate, time, place, and person.

Gait: [ ] walker [ ] cane [ ] others

[ x ] Steady [ ] Unsteady[ ] Sensory and motor losses in face or extremities : Sensory and Motor losslimited

[ x ] ROM limitations:Pt. is able to walk but with assistance

COMFORT/SLEEP/AWAKE:[ x ] Pain Comments

(location “grabe jud kasakit akong tiyan”As verbalized by the pt.

frequencyremedies)

[ ] nocturia[ x ] sleep difficulties “galisod ko og tulog inig

Gabie kay tugnaw gataki-

[ x ] Facial grimaces[ x ] Guarding[ x ] Other signs of pain: pain scale 10/10

[ ] Siderail release form signed (60 +years)



Gan ko” as verbalized byThe pt.

[ ] denied

COPINGOccupation: noneMembers of household: 4 members of the familyMost supportive person: Mrs. Evelyn (mother)

Observed non-verbal behavior: thesignificant others are supportive andattends the needs of pt.

The person and his phone number thatcan be reached any time: not given



IX. NURSING MANAGEMENT

A. IDEAL NURSING MANAGEMENT

NURSING DIAGNOSIS: Infection, risk for Risk factors may include

Inadequate secondary defenses, e.g., decreased hemoglobin, leukopenia, or decreasedgranulocytes (suppressed inflammatory response) Inadequate primary defenses, e.g., broken

skin, stasis of body fluids; invasive procedures; chronic disease, malnutrition

Possibly evidenced by

[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Risk Control (NOC)

Identify behaviors to prevent/reduce risk of infection.

Immune Status (NOC)

Be free of signs of infection, achieve timely wound healing (if present).

ACTIONS/INTERVENTIONS

Infection Protection (NIC)

IndependentPerform/promote meticulous handwashing by caregivers and patient.

R: Prevents cross-contamination/bacterial colonization. Note: Patient with severe/aplastic

anemia may be at risk from normal skin flora.

Maintain strict aseptic techniques with procedures/wound care.

R: Reduces risk of bacterial colonization/infection.

Provide meticulous skin, oral, and perianal care.

R: Reduces risk of skin/tissue breakdown and infection.

Encourage frequent position changes/ ambulation, coughing, and deep-breathing exercises.

R: Promotes ventilation of all lung segments and aids in mobilizing secretions to prevent

pneumonia.



Promote adequate fluid intake.

R: Assists in liquefying respiratory secretions to facilitate expectoration and prevent stasis of

body fluids (e.g., respiratory and renal).

Stress need to monitor/limit visitors. Provide protective isolation if appropriate. Restrict live

plants/cut flowers.

R: Limits exposure to bacteria/infections. Protective isolation may be required in aplastic

anemia, when immune response is most compromised.

Monitor temperature. Note presence of chills and tachycardia with/without fever.

R: Reflective of inflammatory process/ infection, requiring evaluation and treatment. Note: With

bone marrow suppression, leukocytic failure may lead to fulminating infections.

Observe for wound erythema/drainage

R: Indicators of local infection. Note: Pus formation may be absent if granulocytes are

depressed.

Collaborative

Obtain specimens for culture/sensitivity as indicated.

R: Verifies presence of infection, identifies specific pathogen, and influences choice of

treatment.

Administer topical antiseptics; systemic antibiotics.

R: May be used prophylactically to reduce colonization or used to treat specific infectious

process.



IDEAL NURSING CARE PLAN

NURSING DIAGNOSIS: Nutrition: imbalanced, less than body requirements May be

related to

Failure to ingest or inability to digest food/absorb nutrients necessary for formation of normal

RBCs

Possibly evidenced by

Weight loss/weight below normal for age, height, and build Decreased triceps skin-fold

measurement Changes in gums, oral mucous membranes Decreased tolerance for activity,

weakness, and loss of muscle tone

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Nutritional Status

(NOC)

Demonstrate progressive weight gain or stable weight, with normalization of laboratory values.

Experience no signs of malnutrition. Demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight.

ACTIONS/INTERVENTIONS

Nutrition Therapy (NIC)

Independent

Review nutritional history, including food preferences

R: Identifies deficiencies, suggests possible interventions.

Observe and record patient’s food intake.

R: Monitors caloric intake or insufficient quality of food consumption.

Weigh periodically as appropriate (e.g., weekly).

R: Monitors weight loss and effectiveness of nutritional interventions.



Recommend small, frequent meals and/or between-meal nourishment.

R: May reduce fatigue and thus enhance intake while preventing gastric distension. Use of

Ensure/Isomil or similar product provides additional protein and calories.

Suggest bland diet, low in roughage, avoiding hot, spicy, or very acidic foods as indicated. R: When oral lesions are present, pain may restrict type of foods patient can tolerate.

Have patient record and report occurrence of nausea/ vomiting, flatus, and other related

symptoms such as irritability or impaired memory.

R: May reflect effects of anemias (hypoxia, vitamin B12 deficiency) on organs.

Collaborative

Consult with dietitian.

R: Aids in establishing dietary plan to meet individual needs.

Monitor laboratory studies, e.g., Hb/Hct, blood urea nitrogen (BUN), prealbumin/albumin,

protein, transferrin, serum iron, vitamin B12, folic acid, TIBC, serum electrolytes.

R: Evaluates effectiveness of treatment regimen, including dietary sources of needed nutrients.

Administer medications as indicated,e.g.:

Vitamin and mineral supplements, e.g., cyanocobalamin (vitamin B12), folic acid

(Folvite), ascorbic acid (vitamin C);



Nursing Diagnosis: risk for imbalanced Fluid volume include risk factors

inadequate fluid intake, bleeding, hyperthermia

Possible evidenced by:

[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Risk Control

(NOC)

Demonstrate adequate fluid balance as evidenced by stable vital signs, palpable pulses,

normal skin turgor and no edema present.

Actions/Interventions

Independent:note clients age, current level of hydration.

R: this is to provide information regarding ability to tolerate fluid level.

Measure and record I/O.

R:To monitor loss fluid

Note presence of vomiting, liquid stool

R:To include losses in output calculations

Calculate fluid balance(intake>output or output>intake)

R:To prevent fluctuations/imbalances in fluid levels

Auscultate BP, calculate pulse pressure

R:PP widens before systolic BP drops in response to fluid loss.)



Weigh daily or as indicated and evaluate changes

R:Because these may relate to fluid status

COLLABORATIVE:

Administer IV fluids as prescribed

R: to promote fluid management

Assist with rotating tourniquet phlebotomy, dialysis, or ultrafiltration

R: to correct fluid overload situation.

B. ACTUAL NURSING MANAGEMENT (SOAPIE FORM)

S “init lage ako lawas og sakit pud ako ulo” as verbalized by the patient.

O • Increased in body temp. 38c

• Flushed skin, warm to touch

• chills

A Hyperthermia related to illness

P At the end of 30 min. patient’s temp. will be lower down from 38C to 37.5C

I Provided tepid sponge bath May help reduce fever.

Provided adequate fluid intake To prevent dehydration

Reassessed body temperature q 15min.

To determine the effectiveness of theinterventions done.

Monitored client’s temperature,noted shaking chills.

To prevent further complications

Instructed client to have a bed rest. to reduce metabolic demands/oxygenconsumption

Collaborative:Administer antipyretic medication;e.g., paracetamol

To reduce fever and to restore normalbody temperature.

E At the end of the shift, patient’s body temperature was lowered down from 38cto 37.5c



S “Sakit ako tiyan” as verbalized by the patient

O As evidenced by:Facial grimaceGuardingPain scale 7/10

A Acute Pain related to

P At the end of 30 min the patient will be able to verbalize method thatrelief pain

I Independent:-Encouraged use of relation technique such as deep breathing exercise

To minimize pain

-Provided small frequent mealsTo avoid abdominal pain

-Provided position of comfortTo reduce pain and provide comfort

-Encouraged adequate rest periods

To prevent fatigue

Dependent:

- Administer medication as indicated

To reduce pain and muscle spasm

E At the end of 30 minutes the patient was able to verbalized method thatprovide relief.



S “Pila nako ka-adlaw na wala na kalibang” as verbalized by the pt.

O As evidenced by:

- Hypo-active bowel sound

A Constipation related to poor eating habit and insufficient fiber intake

P At the end of 30min. pt wil be able to verbalize understanding about

proper life style modification

I Independent:

-Encouraged activity and exercise as toleratedMay reduce potential for constipation by improving stool

consistency and to stimulate contraction of intestine

-Encouraged adequate fluid intake and high fiber ,fruit juicesTo improve consistency of stool, facilitate passage through colon

-Provided information about relationship between diet and exerciseTo provide proper way of elimination

-Encouraged adequate rest periodsTo prevent fatigue

E At the end of 30 min the patient was able to verbalized understandingabout proper life style modification.



S “Kapoy kayo ako lawas” as verbalized by the patient

O As evidenced by:

- Generalized body weakness

- Assisted in walking

A Activity Intolerance related to body weakness

P At the end of 30min. pt wil be able to indentify tecniques to enhances

activity toleralnce

I Independent:

-Encourage patient to maintain positives attitude such as relaxationtechnique

To enhance sense of well-being

-Provide positive atmosphereTo minimize fatigue

-Provide patient in planning care between rest period and activityTo reduce weakness

-Plan care with rest periods between activities

To reduce fatigue

-Assist client to learn and demonstrate appropriate safety measureTo prevent injury

E At the end of 30 min the patient was able to indentified techniques toenhance activity tolerance



X. DRUG STUDY



Drug Name: Fern-C

Classification: Vitamin B complex with vita. C

Indication: Prevention and treatment of Vitamin C deficiency enhancesimmune system and resistance to fatigue and muscle weakness.

Dosage/route/frequency: I cap BID P.O

Mechanism of action: Collagen synthesis

Contraindications: Renal impairment due to intake of alcohol

Adverse eactions: Drug toxicity and hypersensitivity

Precautions: Note for any intake of medication to prevent auto-immune reaction of physiologic response



Drug Name: Isoprinosine

Classification: Anti-infectives

Indication: Treatment of various viral infection

Dosage/route/frequency: 500mg BID x7 a day

Mechanism of action: Inhibit growth of bacteria or kill susceptible pathogenic bacteria.

Contraindications: avoid taking without meals

Adverse reactions: transient elevation of urine/serum, uric acid level

skin rashes or itching

gi upset, nausea, fatigue/malaise, constipation, polyuria

Precautions: proper dosage of time, amount of dosage intake assessingfor any drug toxicity. Note for severe psychological drugreactions.



Drug Name: Paracetamol

Classification: Antipyretics

Indication: Mild pain and for fever

Dosage/route/frequency: 500 mg 1 tab q 4 hrs PO

Mechanism of action: Inhibits the synthesis of prostaglandin that may serves asmediators of pain and fever, primarily in the CNS

Contraindications: Contraindicated in previous hypersensitivity.Products containing alcohol. Use cautiously in hepatic disease/renal disease

Adverse eactions: GI hepatic failure, renal failureNeutropenia, leucopeniaRash, urticaria

Precautions: May alter result of blood glucose monitoringAdvise pt to avoid alcohol (3 or more glasses per day to avoid

risk of liver damage



Drug Name: Ranitidine

Classification: Anti-ulcer agents (H2 antagonist)

Indication: Inhibition of gastric acid secretion stress ulcer on upper GI

Dosage/route/frequency: 150 mg BID x 7 days

Mechanism of action: Inhibits the action of histamine at the H2- receptors site locatedprimarily in gastric parietal cells resulting in inhibition of gastric acidsecretion

Contraindications: Contraindicated in hypersensitivity. Use cautiously in in renalimpairement ( more susceptible to CNS reactions)

Adverse reactions: CNS: confusion, dizziness, drowsiness, hallucination, headacheArrythmia

Black tongue, constipation, dark stoolAnemia, neutropenia

Precautions: Assess for epigastric and abdominal pain.Monitor CBC with differentiated periodically during therapy



XI. A. REFERRALS AND FOLLOW-UP

MEDICATION Client is advice to follow strict compliance of home

medications, following strict time and continuous antibiotic

treatment followed meds:

Fern C, Isoprenosole, Ranitidine

RATIONALE:

Home medication should be instructed to ensure that the

essential pharmacologic response is effective by proper

elimination of bacteria and viruses by strict compliance of

medications

EXERCISE Patient is advice to have relaxation techniques such as “Fecal

Imagery” to a non-pharmacological interrelation being made.

Assist client with passive and active range of motion exercise.

RATIONALE:

Fecal Imagery is a higher form of therapeutic response to

ensure a non-dependent response top intervention without the

help of pharmacologic indication

TREATMENT Patient is advice to follow:

Promotion of good rest and avoidance of stressful activities

Compliance to medication

Practice relaxation techniques to provide a therapeutic

response such as medication

RATIONALE:

Non-pharmacologic approach provides a holistic care and



ensures client with treatment compliance to be very effective.

OUT PATIENT Instruct client for a follow up check up by giving a note with a

complete date, specific place and time with reservation of the

attending physician to ensure harmonious check-up.

RATIONALE:

Proper place with the proper time ensures collaborative

measures between the client and the hospital staff to ensure

that the instructions are being given with an accurate

information.

DIET Client is advice to eat nutritious foods with fresh fruits and

vegetables. Increase fluid intake at least 8 glasses per day.

Avoid any alcoholic beverages and soda bottled drink.

RATIONALE:

Optimum quality of vegetables, provide vitamins necessary for

growth of client’s physiologic needs.

Increase fluid intake ensures fluid balance in the body system

and essential nutrients for nutritional balance.

Alcoholic beverages prevents and be avoided to eliminate

waste and junk in the body system.

B. EVALUATION AND IMPLICATIONS

After conducting this care study, We were able to appreciate more the essence of utilizing

the nursing process in the care and management of my patient. It was indeed a tough job on



conducting this study yet, it gave us a big impact regarding how useful it is in our chosen

profession. Nursing really demands a tender loving care attitude. It demands patience and it is

calling that cannot be merely taken for granted.

Moreover, this care study taught us to stand on our own by not depending on others just

to make this. This provides us, the students, a big learning regarding on how well we take care

of or patients in the real clinical setting. Most of all, this study teaches the students to provide

clients care more efficiently and competently to achieve an effective and quality nursing care.

XII. BIBLIOGRAPHY

Medical-Surgical Nursing 11th Edition. Suzanne Smeltzer, Brenda Bare, Janice Hinkle,Kerry Cheever. Volume 1. Pp. 1204 – 1207



Nurse’s Pocket Guide (Diagnoses. Prioritized Interventions, and Rationales) 11th

Edition. Mrilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr

PPD’s Nursing Drug Guide 2007 Edition

http://www.emedicine.com/MED/topic850.htm



205 cs -dengue fever

Documents