case study (dhf)

OBJECTIVES

General

This case study aims to identify and determine the general health problems and needs of the patient with an admitting diagnosis of Dengue Hemorrhagic Fever, Type 1. This work also intends to help promote health and medical understanding of such condition through the application of the nursing skills.

Specific

To raise the level of awareness of significant others on health problems that a toddler may encounter.

To facilitate support people in taking necessary actions to solve and prevent the identified problems on the toddler.

To help parents in motivating their child to continue the acquisition of the health care provided by the health workers.

To render nursing care and information to patient and family through the application of the nursing skills.

I. INTRODUCTION

Dengue fever is found mostly during and shortly after the rainy season in tropical and subtropical areas of

Africa Southeast Asia and China India Middle East Caribbean and Central and South America Australia and the South and Central Pacific

An epidemic in Hawaii in 2001 is a reminder that many states in the United States are susceptible to dengue epidemics because they harbor the particular types of mosquitoes that transmit it. Worldwide, more than 100 million cases of dengue infection occur each year. This includes 100 to 200 cases reported annually to the Centers for Disease Control and Prevention (CDC), mostly in people who have recently traveled abroad. Many more cases likely go unreported because some health care providers do not recognize the disease. 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 and dengue shock syndrome also have increased in many parts of the world.

Dengue fever can be caused by any one of four types of dengue virus: DEN-1, DEN-2, DEN-3, and DEN-4. You can be infected by at least two, if not all four types at different times during your lifetime, but only once by the same type.

You can get dengue virus infections from the bite of an infected Aedes mosquito. Mosquitoes become infected when they bite infected humans, and later transmit infection to other people they bite. Two main species of mosquito, Aedes aegypti and Aedes albopictus, have been responsible for all cases of dengue transmitted in this country. Dengue is not contagious from person to person.

Symptoms of typical uncomplicated (classic) dengue usually start with fever within 5 to 6 days after you have been bitten by an infected mosquito and include

High fever, up to 105 degrees Fahrenheit Severe headache Retro-orbital (behind the eye) pain Severe joint and muscle pain Nausea and vomiting Rash

The rash may appear over most of your body 3 to 4 days after the fever begins. You may get a second rash later in the disease. Symptoms of dengue hemorrhagic fever include all of the symptoms of classic dengue plus

Marked damage to blood and lymph vessels Bleeding from the nose, gums, or under the skin, causing purplish bruises

This form of dengue disease can cause death.

Symptoms of dengue shock syndrome-the most severe form of dengue disease-include all of the symptoms of classic dengue and dengue hemorrhagic fever, plus

Fluids leaking outside of blood vessels Massive bleeding Shock (very low blood pressure)

This form of the disease usually occurs in children (sometimes adults) experiencing their second dengue infection. It is sometimes fatal, especially in children and young adults.

II. BIOGRAPHIC DATA

Name: RGL

Address: 757 U. Soliven St., Brgy. Commonwealth, Quezon City

Age: 3 years old Gender: Female Religious Affiliation: Roman Catholic

Marital Status: Single

Room and Bed No.: 428A

Chief Complaint: Fever

Provisional Diagnosis: Dengue Hemorrhagic Fever I

Attending Physician: Dr. Candelaria

III. NURSING HISTORY

A. PAST HEALTH HISTORY

1. Childhood IllnessThe patient had the usual childhood diseases such as measles, mumps, and

chicken pox.

2. ImmunizationThe patient mother and father stated that she was not fully immunized. The

results show that BCG (+), Hepa B (-), DPT (+), OPV (+), Measles (+), MMR (+), Varicella (-).

3. AllergiesThe patient mother stated that she is positive of Cephalexin however she has no

allergic reactions to any food.

4. AccidentsThe patient’s father denied any history of major accident and trauma throughout

her lifespan. Only minor accident took place, like playing outside and accidental falls.

5. HospitalizationsThe patient’s mother and father states that this was her 1st time being admitted

to the hospital.

6. Medications used or currently takenThe patient only takes 5 types of medications. These are Paracetamol 120

mg/5ml, 5ml q 4 hours prn, temperature > 37.8 degrees Celsius. The second medication is Ibuprofen (Dolan) 200 mg/5ml, 3ml q 6 hours prn, temperature > 38.5 degrees Celsius. Third is Iterax 5ml Bid. Nutrizinc syrup 5ml OD. Last but not least, Ceftriaxone 450mg Via IV drip q 12hours (ANST). Further explanation about the drug will be discussed later on the case study.

7. Foreign travelThe parent’s stated that they have not been travelling frequently. They just visit

their relatives in Masbate once in a year.

B. HISTORY OF PRESENT ILLNESS

The patient present condition started 1 week prior to PTC prior to consultation. She experienced on and off fever undocumented. No signs of cough and colds during that time. She had a very low resistance because she has a lack of or weak appetite. Since this was not any major case, she was just given Paracetamol 5 ml.

3 days PTC - Patient still was in a febrile state having hyperthermia with rashes. This time the patient had vomited of previously ingested food. Lack of appetite was still into play. She was then consulted to a private physician. She was advised to take several medications which will help her relieve some pain.

2 days PTC - Patient started to have rashes after taking Cephalexin.

1 day PTC - Patient still had fever and was known as febrile (39- 40 degrees Celsius). After having an abdominal pain during this time, the patient’s parents went off to consult.

C. FAMILY HISTORYThe patient has no family history of diseases (especially genetic ones). (-) of

hypertension, Diabetes Mellitus, PTB, Malignancy, Heart Disease, Kidney Disease, Liver disease, Thyroid Disease.

D. Developmental HistoryThe patient had social smile at 3 months, was able to roll over at 5 months and

sit without support at 6 months. At present, the patient can climb stairs with alternating feet, and can use 3-word sentences e.g. “I love you”.

IV. PATTERNS OF FUNCTIONING

A. PSYCHOLOGICAL HEALTH

1. Coping Pattern

As a child, Ms. RGL can not completely verbalize how well she copes up with her environment. The patient, when she doesn’t get what she wants, she easily gets agitated. She bangs the door, throws her things on the floor, and the likes, until her parents try to make things up for her. After doing so, everything is settled already. She gets what she wanted, or almost. When on the hospital, she just watches the television to alleviate her sadness and to divert her thoughts of being hospitalized to other happy feelings.

Analysis:

Coping is dealing with changes in one’s life. It may be a successful or unsuccessful one. Coping strategies – a way of responding to a change in the environment or situation – varies from person to person. One thing is for sure, there is never only one way to cope. It can be effective which results to adaptation, or ineffective which results to mal-adaptation.

Interpretation:

The patient’s coping mechanism is effective for her age because after doing the said acts and gestures, she gets what she wanted coping to what she is prior to the coping situation.

2. Interaction Pattern

Objectively, the patient is very close to her parents. She cuddles them and seeks for their attention constantly. “Pag may naririnig na salita, ginagaya niya” as verbalized by the mother. This shows how the child is curious with expanding her very young developing mind. Through this, she also shows her response to people in a mature way. She has many friends (as stated by the mother) whom she bonds with during playtime. She also gets into trouble regarding petty things, but sees to it that she doesn’t get herself much too involved in the situation. She likes to be the center of attention and wants to be treated like a baby. At a tender age, she could decipher things as to what is right or wrong based on her models of behavior (her parents), but when she feels a little mischievous she break the rules, but manages to sneak out of trouble as her parents tend to cut her some slack. Once she is introduced to someone, she immediately remembers that person.

Analysis:

According to Jean Piaget’s stages of development, children ages 2-7 tend to exhibit extreme egocentrism (which started at the sensorimotor stage and will peak at this stage) and then weakens, a developmental stage which Piaget refers to as the Preoperational stage. Egocentrism is shown by the patient through the desire of both of her parent’s attention and minimizes when she responses to other people and make friends with others. Furthermore, he stated that:

# The child performs an action which has an effect on or organizes objects, and the child is able to note the characteristics of the action and its effects.

# Through repeated actions, perhaps with variations or in different contexts or on different kinds of objects, the child is able to differentiate and integrate its elements and effects. This is the process of "reflecting abstraction"

These traits are apparent in the patient’s attitude towards new ideas and actions.

Source: http://en.wikipedia.org/wiki/Jean_Piaget#The_stages_of_cognitive_development

Interpretation:

For a child her age, her interactive behaviors are predominantly normal.

3. Cognitive Pattern

There are no abnormalities in the client’s mental functioning. She is able to speak clearly and her senses work well. She is not yet schooling. However, she already knows the Alphabet, Numbers and Shapes. She loves to watch educational shows in DVD that were bought by her parents.

Analysis:

The major development milestone during the preoperational period (2 - 6/7 years) is the development of the symbolic function, or the ability to use symbols such as words, images, and gestures to represent objects and events. This can be seen in the rapid development of language, in imaginative play, and in an increase in deferred imitation.

Source: http://highered.mcgraw-hill.com/sites/0072820144/student_view0/chapter9/

Interpretation:

The client’s mental functioning is normal for her age.

4. Self-Concept Pattern

The patient’s father stated that whenever his child is teased as an ugly and unattractive girl, her response was “Hindi ako naniniwala, maganda kaya ako.”. She believed in herself and very contented and satisfied on how she looks. Sometimes she becomes moody but most of the time she faces everyone especially the people she loves with a big smile. She loves to meet people and she wants to meet more friends in the future.

Analysis:

Self-concept or self identity refers to the global understanding a sentiment being has of him or her. It presupposes but can be distinguished from self-consciousness, which is simply an awareness of one's self. It is also more general than self-esteem, which is the purely evaluative element of the self-concept. The self-concept is composed of relatively permanent self-assessments, such as personality attributes, knowledge of one's skills and abilities, one's occupation and hobbies, and awareness of one's physical attributes. Nevertheless, a person's self-concept may change with time, possibly going through turbulent periods of identity crisis and reassessment. The self-concept is not restricted to the present. It includes past selves and future selves. Future selves or "possible selves" represent individuals' ideas of what they might become, what they would like to become, and what they are afraid of becoming. They correspond to hopes, fears, standards, goals, and threats. Possible selves may function as incentives for future behavior and they also provide an evaluative and interpretive context for the current view of self.

Interpretation:

The patient is confident, happy, and satisfied and without having any difficulty of her self-concept.

5. Emotional Pattern

http://highered.mcgraw-hill.com/sites/0072820144/student_view0/chapter9/

The patient is a three-year old girl. Her parents preoccupy the patient with other things. “Hindi pa naman namomroblema,” as claimed by the mother. According to them, she alleviates her sadness through watching the television or just simply playing with other children in their neighborhood. In times of sickness, she makes a way to take a lot of rest to regain energy. They feed her with foods that she wants in order to exhibit happiness in her character especially when she is to be reinforced for a good attitude that she shows.

Analysis:

Toddlers, however, don't yet have this power to rationalize. They don't know which emotions to ignore and which ones are justified. This is why when a child falls, her first reaction is often to turn and look at Mom's face. Do you look afraid? Sad? Angry? This emotional referencing helps your child learn the appropriate responses to difficult situations. "Kids need to know, 'I am feeling something but I am going to be okay,'" Van Bortel says.

Toddlers are also becoming more self-aware. "Put an 18-month-old in front of a mirror with a little rouge on his nose, and he recognizes himself and will try to remove the rouge. Before 18 months, they don't," says Matt Hertenstein, a psychologist and lead researcher at the Infant Discovery and Emotion Lab at DePauw University, in Greencastle, Indiana. Burgeoning self-consciousness brings with it several new emotions, such as embarrassment. When your potty-training 2-year-old has an accident at daycare and is laughed at, he understands that others are making fun of him. But this new emotional understanding also has a positive side: Your toddler now can experience the pride that comes from a job well done. Praise him for a colorful picture he drew or a tower he carefully built, and he'll smile brightly and puff up his chest.

Source: http://www.parents.com/baby/development/behavioral/help-kids-deal-with-emotions/?page=3

Interpretation:

The patient does have variations in terms of emotion. It shows no signs of deviations from that of the normal.

6. Sexuality

http://www.parents.com/baby/development/behavioral/help-kids-deal-with-emotions/?page=3

http://www.parents.com/baby/development/behavioral/help-kids-deal-with-emotions/?page=3

The patient has normal reproductive system. Though still young, her pattern of sexuality is not yet disturbed nor agitated since she is not yet married and remain single as she portrays the function of a child in the family. The patient has identified the gender she has, her favorite color, as well as the things she wants to have as to imbibe her sexuality.

Analysis:

Sexuality is a crucial part of a person’s identity. Sex is central to who we are, to our emotional well-being, and to the quality of our lives. All people have the potential to positively experience and pleasurably express their sexuality. One does not have to be in relationship to be sexual. The idea that you need another person to feel sexual is both disempowering and untrue. Clients do not leave their sexuality behind when they enter the health care system – their sexuality is always part of them.

Source: Kozier, Barbara, et. al., Fundamentals of Nursing, Concepts, Process and Practice: 7th ed, © 2004, Pearson Education, Inc., 73.

Interpretation:

The patient has not experienced sexual intercourse since she does not have the knowledge or information in relation to the function of her body parts and still innocent about the reproduction process yet her sexuality pattern is still normal because her sexuality is always a part of herself.

7. Family Coping Pattern

The patient came from a closely bonded and loving family. Her parents are alive and she has no siblings.

Her parents stated that they experience little misunderstandings at home. When misunderstandings arise, their daughter cries when she sees them, and they quickly resolve the problem.

As for their bonding patterns, they eat outside, go out for a stroll at the mall during Sundays and watch TV at home on weekdays. They give much attention to the patient. They see to it that the patient feels happy whenever they do such activities.

Analysis:

Family coping mechanisms are the behavior families use to deal with stress or changes imposed from either within or without. Coping mechanisms can be viewed as an active method of problem solving developed to meet life's challenges. The coping mechanisms families and individuals develop reflect their individual resourcefulness. Family may use coping mechanisms rather consistently over time or may change their coping strategies when new demands are made on the family.

The family's ability to cope with the stress of illness depends on the member's coping skills. Families with good communication skills are better able to discuss how they feel about the illness and how it affects family functioning. They can plan for the future and are flexible in adapting these plans as the situation changes.

Source: Kozier, Barbara, et. al., Fundamentals of Nursing, Concepts, Process and Practice: 7th ed, © 2004, Pearson Education, Inc., Page 193-195

Interpretation:

The way in which the patient and her family cope with her present illness as well as other problems they encountered is normal, because they can deal with the stress these problems are putting on them and they can find a way to solve and handle them.

B. SOCIO-CULTURAL PATTERNS

1. Cultural Pattern

The patient grew up in the city. Although she went to Masbate already, the province of her parents, no particular beliefs and/or values had been procured. She acquired values from her parents and the people around her e.g. friends and relatives like being obedient with what the parents say. On the other hand, as a toddler, there’s a point wherein she creates her own values, typically going through a period of extreme negativism. She doesn’t want to do at times what her parents want her to do. Her reply to some of their requests is a very definite “no.”

Analysis:

It is easy for parents to believe their authority is being questioned when this happens and to worry their child is becoming so disrespectful he or she will have difficulty getting along in the world. They can be baffled by the extreme change from a happy, cooperative infant who lived to please them to this irritating, uncooperative child. They may need some help to realize this is not only a normal phenomenon of toddlerhood but also a positive stage in development. This change indicates their toddler has learned he or she is a separate individual with separate needs. It is important that toddlers do this if they are to grown up to be persons who are independent and able to take care of their own needs and desires.

Source: Pilliteri, Adele. Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th Edition ©2007. Philadelphia, USA, Lippincott Williams & Wilkins, p. 875

Interpretation:

The cultural pattern of the client is focused on the development of a toddler as a growing child and therefore be considered as accepted within the normative spectrum of a family with a toddler.

2. Significant Relationships

The significant others considered by the patient are mainly her parents and maternal aunts and uncles. She looked upon her parents as the greatest people in the world – as far as they’re concerned. Sometimes, these relationships render reinforcement to the child specifically positive reinforcement. The aunts and uncles give material things to the client such as toys making her delightful at times and ceasing her to do what she should not do. Interaction of the client and her significant others sustains the toddler’s love of silliness, laughter, and joy.

Analysis:

Parents (and significant others) also must grow during the period of toddlerhood. Their task is to support their child’s growing independence with patience and sensitivity and to learn methods for handling the child’s frustrations that arise from the quest for autonomy.


Interpretation:

The social life of the patient is mainly sustained by her relationship with her parents and relatives which in turn contributes to the social development of the toddler.

3.Recreation Pattern

The patient loves to play most of time alone and seldom with other children. Though she has no idea regarding the significance of engaging with recreation, at least she can experience its essence. Some of the things she does during playtime are: playing toy cars and riding a small bike. At home, her pastime is watching TV, particularly, the “Spongebob” show.

Analysis:

The toys toddlers enjoy most are those they can play with by themselves and that require action. Trucks they can make go, squeaky frogs they can squeeze, waddling ducks they can pull, rocking horses they can ride, pegs they can pound, blocks they can stack, and a toy telephone they can talk into are all favourites. These are all toys children can control, giving them a sense of power in manipulation, an expression of autonomy.


Interpretation:

The toddler’s playing behaviour is within the continuum of wellness behind the reason that it encompasses the development of a sense of autonomy as described by Erikson.

4. Environment

The patient’s mother and father depicted their residence as well-ventilated, bungalow type with one room. The house space is conducive according to their perception. The house is surrounded by waterways that are stagnant which became the ground for the proliferation of mosquitoes.

Analysis:

Environment is the sum total of all external condition and influences that affects the development of health of an individual. It has a strong influence on health promotion and illness-prevention activities of individuals. A safe and healthy environment can be an indicator of a healthy population because environment is a reflection of the people living in it.

Interpretation:

Considerable factors can be seen in the patient’s environment that contributed to the transmission of the Dengue virus from the vector to the patient herself.

5. Economic

"Sapat naman ang kinikita naming mag-asawa para sa aming pang-araw-araw. Nakapagtatabi pa rin kami ng extrang pera just in case na kailanganin sa mga emergency tulad ng ganito", the mother said. The father is an electrical engineer and the mother is a plain housewife. Their income is sufficient enough to maintain their day-to-day living.

Analysis:

Financial needs of every person vary considerably. Food, medical cost, and other expenses are often a financial burden. Adequate financial resources will enable a family to remain independent.

Interpretation:

The economic status of the patient’s family is stable that even during health crisis; her family can support their needs.

C. SPIRITUAL PATTERNS

1. Religious Beliefs and Practices

The patient is a Jehovah’s witness, a restorationist, millenarian Christian denomination. According to the father of the patient, they seldom attend their meetings for worship that are usually celebrated during Saturdays and Sundays because he is too busy with work. The patient only knew Jesus Christ as “Bro” in the primetime show in one of the local TV networks.

Analysis:

Children have no concept of right or wrong and beliefs. However, children’s beginning of faith is established with the development of trust through their relationship with their primary caregiver. Children imitate the religious gestures and behaviors of others without comprehending any meaning or significance to the activities.

Interpretation:

At early age, patient tries to assimilate some of the values and beliefs of their parents. Parental attitudes toward moral codes and religious beliefs convey children what they consider to be good and bad. The patient’s state of religiosity is still appropriate for her age.

2. Values and Valuing

As a toddler, the patient’s values are not yet fully developed. According to her parents, her values and attitude are just the same with any other 3 year-old. “Mabait naman siya, may time na aburido ‘pag bagong gising”; “Mapili siya sa pagkain, ‘pag ‘di gusto ang ulam di kumakain”; “Nagagalit, nagwawalk-out at iiyak siya pag ‘di nabibili ang gusto” as verbalized by the parents.

The patient’s parents believe that their daughter’s values can be change through time and constant support. According to them as early as possible they want to teach their daughter values that can mold her to a better person. For attitude,“Palagi namin siyang sinasabihan na ‘wag mag sinungaling kasi magagalit si Jesus pag nagsinungaling ang bata”, “ Sinasabi rin namin ‘wag makipagaway sa kalaro dahil masama ‘yon”. For health, “Sinasabihan rin namin siya na kumain ng gulay para lumakas ang katawan” and for spirituality, “tinuturuan namin siya na magsimba mag dasal every night” as verbalized by the parents. They teach these values to help her in attaining a clever personality/character in life.

Analysis:

Values are learned through one’s observation and experience. As a result, it influences one’s action, decision and perception. Also values serve as a guide in one’s life. If values are well endowed to an individual, it aids to become a better person.

Interpretation:

The patient is still in the stage of egocentrism where she is focused to herself and own perspective that’s why her values are not yet fully developed. But through constant support from her parents she can develop her own values that can make her a better person and be her guide in achieving well-lived life.

V. ACTIVITIES OF DAILY LIVING

ACTIVITIES OF DAILY LIVING

BEFORE HOSPITALIZATION

DURING HOSPITALIZATION

ANALYSIS AND INTERPRETATION

NUTRITION

The client as a toddler is not aware about the significance of a balanced diet as well as with the appropriate foods to be taken at her age. She just leans on her parent’s customary way of acquiring nutrition. Behind the fact that her parents are lacking sufficient knowledge about proper nutrition to be imposed to her, she often eats a meal comprising of less rice and selected viand (dishes based on her taste preference). She’s weak when it comes to eating major meals (breakfast, lunch, and supper). As claimed by the parents, the client usually takes “junk foods” on her diet rather than the foods on their table. In addition, the mother verbalized, “Mahina siya kumain ng kanin at ulam pero madami naman uminom ng gatas (commercially prepared milk).” Regarding the water intake, the client

The patient is subjected to DAT (diet as tolerated) except for dark-colored foods.

The patient is advised to increase fluid intake as tolerated. She still finds it hard to elevate the fluid volume of her body drinking only 250 ml of water a day.

The patient is experiencing a loss of appetite. She can’t consume a considerable amount of nutrients that are needed by her body for energy and strong systemic functions. She just usually eats “lugaw”.

Analysis:

Parents may become frustrated when trying to provide adequate nutrition for their toddler because of a toddler’s varying and unpredictable appetite and food preferences. Although a toddler’s daily food consumption may vary greatly, energy needs are generally met when sufficient food is supplied in a positive environment. Children ages 1 to 3 years should consume 1,300 kcal daily. Protein and carbohydrate needs are often easily met during the toddler period; diets high in sugar should be avoided. Fats should generally not be restricted for children under 2 years old should consume no more than 30% of total daily calories from fat. Adequate calcium and phosphorus intake is

drinks approximately one glass of water according to her mother on a daily basis. The mother reiterated, “Kaunti nga uminom ng tubig, nakakailang bote naman ng gatas sa araw at gabi(about 6 bottles in the day and 2 bottles at night).” The parents are not prompted to render the necessary dietary interventions for their child and so they just accept the way she eats and drinks.

important for bone mineralization. Milk should be whole milk until age 2 years after which 2% milk can be introduced.

Source:Pilliteri, Adele. Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th Edition ©2007. Philadelphia, USA, Lippincott Williams & Wilkins, p. 870

Interpretation:

The patient’s diet before hospitalization and the diet during her stay in the medical center are not sustaining the appropriate and adequate nutrition required for a toddler of her age. She lacks protein for tissue building in her diet at present because her meals consists foods rich in carbohydrates, seldom in fruits and vegetables. The parents need to empower their roles in promoting adequate intake of a

well-balanced diet of their child. Feeding practices to avoid are giving large amounts of sweets or chips and drinking softdrinks(can induce imbalance of calcium and phosphorus) as they have little nutritional value.





ELIMINATION

DEFECATIONThe patient takes a bowel movement once or twice a day. The color is yellowish brown, pungent in odor, and the consistency is semisolid (tubular). Bowel elimination is not quite hard to perform (without any physiologic and/or psychologic interferences). She’s under toilet training.

MICTURITIONThe patient voids an average of 4 times a day. Urine color is yellow with aromatic smell. She doesn’t felt pain or difficulty in urinating (dysuria). She’s starting to be trained in the toilet.

PERSPIRATIONThe patient perspires a lot due to hot climate especially at noon time.

DEFECATION The patient

defecates at least 2 times per day resembling the stool of a goat (small, rounded fecal material).

Pain is not elicited during the process of excretion

Fecal color is dark brown

Consistency is semisolid

Bowel control is exhibited

MICTURITION The patient

urinates less often than prior to hospitalization due to her decreased intake of fluids (2x a day – 100 ml/void)

The color is yellow without unpleasant odor

There’s no phenomenon of dysuria

Urinary control is exhibited

PERSPIRATION The patient

experiences perspiration

Analysis:

Normal Characteristics of

Stool

Volume – variableColor – Child: yellow to brownOdor – pungent; may be affected by foods ingestedConsistency – soft, semisolid, and formedShape – formed stool is usually about 1 inch 92.5 cm) in diameter and has the tubular shape of the colon, but may be larger or smaller, depending on the condition of the colonConstituents – waste residues of digestion: bile, intestinal secretions, shredded epithelial cells, bacteria, and inorganic material (chiefly calcium and phosphates); seeds, meat fibers, and fat may be present in small amounts

Source:Taylor, Carol et al., Fundamentals of

during the elevation of body temperature above normal even though the room where she stays is air-conditioned.

Nursing: The Art and Science of Nursing Care, 5th edition. Lippincott Williams and Wilkins 2005. p.1346

Normal Characteristics of

Urine

Color – a freshly voided specimen is pale, yellow, straw-colored, or amber, depending on its concentration.Odor – normal urine smell is aromatic. As urine stands, it often develops an ammonia odor because of bacterial actionTurbidity – fresh urine should be clear or translucent as urine stands and cools, it becomes cloudypH – the normal pH is about 6.0, with a range of 4.6 to 8Specific Gravity – 1.010 to 1.025Constituents – Organic constituents of urine include urea, uric acid, creatinine, hippuric acid, indicant, urine pigments, and undetermined nitrogen. Inorganic constituents are ammonia, sodium,

chloride, traces of iron, phosphorus, sulphur, potassium, and calcium

Source:Taylor, Carol et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 5th edition. Lippincott Williams and Wilkins 2005. p.1297

Interpretation:

The elimination pattern (before and during hospitalization) has points of deviation from normal. The patient’s urine output during the hospital stay is not sufficient (should be about 500 to 600 ml) wherein she’s not abiding with the order of increasing her fluid intake. On the other hand, she perspires excessively during hospitalization which can probably lead to dehydration if no proper intervention will be done. The parents should encourage their child to comply with an increased fluid intake to restore adequate

level of hydration.





EXERCISE

The toddler is full of energy and has an overwhelmingly intense desire to move around and explore her environment. She doesn’t have a planned and structured form of exercises behind the reason that it’s still beyond her consciousness as a child. But she engages in physical activities that she doesn’t know are already considered as exercises. Her mother said that she plays almost everyday particularly in the afternoon. She loves to push and pull toys (toy cars to be specific). She rides in a small bike around their house. She’s not placid and sedentary rather she’s very active most of the time.

The patient is deprived of physical activities that promotes skeletal muscle contractions due to her condition

The patient is in ambulation which means she can just walk at least going to the comfort room

Although she’s under complete bed rest, she can still practice ROM exercises that she does unnoticed e.g. flexion/ extension of arms/legs, abduction/ adduction of the arms/legs which can be observed when she eats and goes to the C.R.

Analysis:

Walking involves a wide stance and unsteady gait, thus the term toddler. From ages 1 to 5 years, both gross and fine motor skills are refined. For example, by 3 years of age is the toddler able to do the following? Walk up steps

without assistance Balance on one

foot, jump, and walk on toes

Copy a circle Build a bridge

from blocks Ride a 3-wheeled

bikeImmobility can impair the social and motor development of young children.

Source:Kouzier, Barbara et al. Fundamentals of Nursing: Concepts, Process, and Practice, 8th edition, Volume 2 ©2008. Pearson Education, Inc., p. 377 and p. 1116

Interpretation:

The patient can still continue her need for physical activity in the hospital because she’s only ambulatory not immobile, capable of walking without assistance at times but with the help of her parents sometimes when she’s experiencing weakness. She’s not immobile which means she can still perform a number of ROM (range-of-motion exercises) maintaining her muscle tone and developing her motor skill as part of a child’s development.





HYGIENE

The patient takes a bath 2x a day (day and night). The mother doesn’t ensure a diet appropriate for her toddler, which can actually contribute to clean and intact skin. The patient’s oral hygiene practice includes brushing her teeth twice a day only not visiting the dentist at least once per annum. In terms of grooming, the mother makes sure that the hair of her daughter is always kept clean, combed, and brushed regularly. She also cleans the nails of her child and cut them at an appropriate length. To maintain the patient’s skin complexion, the mother applies baby lotion at night after taking a bath and before her child goes to sleep. The mother puts baby powder at times to the child’s back. The toddler doesn’t have deep

The patient cannot perpetuate her needs for self-care because of her condition. She seldom brushes her teeth behind the fact that her gums and lips are becoming dried. As a substitute for full bath, her mother applies a tepid sponge bath for her child as a directive of the attending physician to lower the body temperature.

Analysis:

The time for a toddler’s bath should depend on the parents’ and the child’s wishes and schedule. Some parents prefer to bathe a toddler before the evening meal because it has a quieting effect and prepares a child for eating; others prefer to give it at bedtime because it has a relaxing effect and helps the child sleep. The time, however, is not as important as the attempt to establish a sense of routine, a sense that life has order.

Source:Pillitteri, Adele. Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th Edition © 2007. Philadelphia, USA Lippincott Williams & Wilkins, p. 874

appreciation between hygiene and over-all well-being for she’s still in the process of acquisition of the significance of personal hygiene. The child’s hygienic preferences are often followed by her mother.

Interpretation:

The patient’s hygienic pattern falls within a normal scale (appropriate for a toddler). There are deviations from standard due to hospitalization and to her skin condition (turgor and dry lips). After discharge, the patient should recuperate a good personal hygiene as similar from her hygiene before she was hospitalized.


BEFORE HOSPITALIZATION DURING HOSPITALIZATION


SUBSTANCE USE

The mother verbalized, “Pinapainom ko siya ng vitamins gaya ng Ceelin (Vitamin C) at Nutrillin (Multivitamins). Kapag nilalagnat siya, pinapainom ko ng Tempra (Paracetamol).” The family of the child adheres to self-medication. When the patient is at the onset of cough and colds, the mother lets her child take Neozep(Phenylpropanolamine) or Solmux (Carbocisteine)

The patient only takes the medications prescribed by the attending physician whether thru IV or by mouth.

Analysis:

Substance use especially intake of beneficial substances can be imperative for a better health if taken under moderation and more so, with a doctor’s consent but when elevated to an abused state has come to refer to overindulgence in and dependence on a chemical leading to effects that are detrimental to the individual’s physical and mental health, or the welfare of others.

Source: Case Study by Melencio, John Alex, Miane, Jomarlo, et al under the supervision of Marilou Choa,

MAN, RN.

Interpretation:

The patient is not going through any kind of substance abuse. Her parents should be notified regarding the right medications that their child must take if for an instance, the toddler has a pathologic disease not just mere symptom (cough/colds). They should learn the importance of interventions by health care workers e.g. medical doctor in terms of health restoration.





SEXUALITY

According to the mother, the patient has become more curious about her own body when she turned to be a toddler than when she was an infant. “Minsan nga tinatanong niya kung babae daw ba siya”, the mother alleged. This statement gives evidence to the increased awareness of the child of her sex. The father further added, “Naglalaro siya ng kotse-kotsehan at espa-espada (toys) minsan kasama mga kalaro niya. Puro lalaki kasi ang mga kalaro.” This discourse illustrates the child’s imitation of the behaviour of the common people (playmates) who usually engages with her during playtime.

Sexual expressions are not exhibited e.g. exploring the genitals when there’s bowel movement or urination. Nonetheless, the patient is still a toddler so she doesn’t have the urge or the idea about the consequent outcome of doing such act.

Analysis:

Both mothers and fathers should cuddle and touch babies. During the child’s first three years, he or she is learning what it means to be a boy or a girl. Give your child the opportunity to explore a range of roles and activities that are not restricted by barriers that say “little girls do this,” and “little boys don’t do that.” Your child is learning about caring for others, sensitivity to feelings and solving problems.

Source:Hickling, Meg. Speaking of Sex: Are You Ready to Answer the Questions Your Kids Will Ask?. British Columbia: Northstone Publishing 1996

Interpretation:

The child’s sexuality pattern is customary in toddlerhood. To manage the patient’s gender identity and gender role, the parents should start orienting their offspring about the ways of living a girl pursues, how she acts, behaves or thinks. In this case, she’s readily in touched with boys so the parents must conduct regular talks with their child regarding the qualities of being a girl in order to achieve the appropriate gender and roles that she should develop.





SLEEP ANDREST

The patient’s mother said that her child usually sleeps 12 hours on a daily basis. Nevertheless, the toddler takes some naps during the day averaging 2 naps. Although at times, noises are around, she settles better if the environment is quiet and when she places her body in a blanket. She has no sleeping problems. No interference is observed. The mother described their home setting as conducive for sleeping.

The father said, “Paputul-putol ang tulog niya (patient) kasi laging may pumupunta na tumitingin ng temperature niya.” Even if the patient’ sleep is hindered most of the time in her stay in the hospital, she tends to sleep and rest as her pastime. The parents perceive that their child still feels good as if she really sleeps adequately.

Analysis:

Between 12 and 14 hours of sleep are recommended for children 1 to 3 years of age. Most still need an afternoon nap, but they need for midmorning naps gradually decreases. The toddler may exhibit a great deal of resistance to going to bed and may awaken during the night. A security object such as a blanket or stuffed animal may help. Sleep and rest are vital for optimal psychological and physiological functioning.

Source:Kouzier, Barbara, et al. Fundamentals of Nursing: Concepts, Process, and Practice, 8th Edition. Pearson Education, Inc. © 2007, p. 1167

(modified)

Interpretation:The patient’s sleep and rest in her daily routine are considered sufficient for her age. With the aim of promoting a good sleeping environment, the parents can learn to comfort their child, keeping the lights low and using as soft voice and as much as possible overcome the sound interference in the surrounding.

VI. PHYSICAL ASSESSMENT

Vital Signs: Actual Finding Normal Finding Analysis and Interpretation

1.Temperature 39.80C

Normal body temperature ranges

from 36.50C up to 37.50C or 96.8 - 98.60F and normally deviates

higher or lower in some points

depending on environmental

condition and activity.Kozier and Erb’s (2008)

Fundamentals of Nursing 8th Edition:

published by Pearson Education. Inc.

p.534

Abnormal. It indicates pyrexia/hyperthermia/

fever

2. Pulse Rate

110

Pulse rate of a toddler is ranging from 80-140 bpmTaylor (2005) Fundamentals of

Nursing 5th Edition: published by

Lippincott Williams and Wilkins.

p.525

Normal

3. Respiratory Rate

32

Respiratory rate of a toddler is ranging from 20 -40 bpm

Taylor (2005), Fundamentals of

Nursing 5th edition p.525

Normal

4. Blood Pressure

90/60

Blood pressure of toddler is 90/55 but it

can also vary individually

Carol Taylor, Fundamentals of Nursing

5th edition p.525

Normal

PART 1:

Body Part Actual Findings Norms and Standards Analysis and Interpretation

1.Height 4’11 According to the Body Mass Index (BMI)

Chart, BMI of 18.6-22.9 is normal, <18.5 is underweight, > or =

to 23 is overweight(DOH book p. 202)

Underweight. It implies unavailability of

adequate food and nutrition for a healthy

body.

2. Weight 12.7 kg

GENERAL SURVEY:

1. Body built in relation to age, lifestyle and health. Client’s body built is

not appropriate for her age

Proportionate, varies with lifestyleKozier and Erb’s (2008) Fundamentals

of Nursing 8th Edition: published by

Pearson Education. Inc. p.572

Abnormal. It indicates lack of

nutrition.

2. Posture and gait, standing, sitting and walking.

Always sleeping and restless

Relaxed, erect posture and coordinated

movements Kozier and Erb’s (2008) Fundamentals



Abnormal. It implies an illness state

(lethargy).

3. Overall hygiene and grooming. Clean and Neat

Clean, neatKozier and Erb’s (2008) Fundamentals



Normal

4. Body and breath odor.

No body and breath odor

No body and breath odor relative to work or exercise; no breath

Normal

odorKozier and Erb’s (2008) Fundamentals



5. Signs of distress in posture or facial expression.

No distress noted No distress notedKozier and Erb’s (2008) Fundamentals



Normal

6. Obvious sign of health and illness. Weakness noted Healthy appearance

Kozier and Erb’s (2008) Fundamentals



Abnormal. It denotes an illness state.

7. Client’s attitude.

Not Cooperative

Cooperative and able to follow instructions




Abnormal. It points out her irritability to

sickness.

8. Note client’s affect/mood; appropriateness of the response.

Appropriate to the situation

Respond appropriately to the

situationKozier and Erb’s (2008) Fundamentals



Normal

9. Quantity and quality of speech.

Understandable

Understandable, moderate pace; clear tone and inflection;

exhibits thought association




Normal

10. Relevance and organization of thoughts. Makes sense

Logical sequence; makes sense; has sense of reality


Normal



SKIN:

1. Color, uniformity of color and appearance.

Brown skin tone with rashes on the back of

the body

Varies from light to deep brown; from ruddy pink to light pink; from yellow

overtones to olive.Generally uniform

except in areas exposed.




Abnormal. It suggests a sign of hemorrhagic

fever(petechiae).

2. Presence of edema.

No edemaNo edema




Normal

3. Skin lesions, according to location, distribution, configuration, size, shape, type or structure.

No lesions or skin abrasions

Freckles, some birthmarks, some flat

and raised nevi; no abrasions or other

lesions




Normal

4. Skin temperature.Generalized hot

temperature

Uniform within normal range




Abnormal. It signifies generalized

hyperthermia/fever.

5. Skin turgor.Skin moved back

slowly when pinchedWhen pinched, skin

springs back to previous state



Pearson Education. Inc.

p.579

Abnormal. It may indicate dehydration or deficient in body

fluids.

NAILS:

1. Plate shape, curvature and angle.

Convex curvature with an estimated angle of about 160

degrees.Long clean nails.

Convex curvature with an estimated angle of about 160

degrees.Kozier and Erb’s (2008) Fundamentals



Normal

2. Fingernails and toe nail bed colored.

Pink in colorvascular

Highly vascular and pink in light-skinned; dark skinned clients

may have black pigmentation in

longitudinal streaks.Kozier and Erb’s (2008) Fundamentals



Normal

3.Nail TextureSmooth

Smooth textureKozier and Erb’s (2008) Fundamentals



Normal

4. Tissues surrounding the nails. Intact epidermis

Intact epidermisKozier and Erb’s (2008) Fundamentals



Normal

5. Blanch test of capillary refill. Nail color readily

Prompt return of punk or usual color Normal

returns when pinched.

(generally less than 4 seconds).




HEAD

SKULL:

1.Size, shape, and symmetry of the skull Rounded,

symmetrical, smooth skull contour, no

extra prominences.

Rounded, symmetrical, smooth

skull contour, no extra prominences.




Normal

2. Nodules, masses, and depressions.

Smooth, no nodules or masses.

Smooth, uniform in consistency, absence of nodules or masses.Kozier and Erb’s (2008) Fundamentals



Normal

SCALP:

1. Color and appearance.

No depressions, white in color, no visible

dandruff flakes.

No depressions; smooth; inelastic;

with even coloration.Kozier and Erb’s (2008) Fundamentals



Normal

2. Areas of tenderness.

No tenderness noted No tenderness Normal

HAIR:

1. Evenness of growth, thickness or thinness over the Hair is evenly

Evenly distributed hair, thick hair.

Kozier and Erb’s (2008) Fundamentals Normal

scalp. distributed and thick. of Nursing 8th Edition: published by


2. Hair texture, color and oiliness.

Hair is straight, no infection or

infestation noted.

Silky, resilient hair; no infection or infestation.




Normal

FACE:

1. Facial features and symmetry of facial movement.

Symmetrical facial features and

coordinated facial muscle movement.

Symmetric or slightly asymmetric facial

features; palpebral fissures equal in size;

asymmetric nasolabial folds.




Normal

EYES

EYEBROWS:

1. Hair distribution, alignment, quality movement.

Hair evenly distributed and

symmetrically aligned with equal movement.

Hair evenly distributed; skin intact; eyebrows

symmetrically aligned; equal

movement.Kozier and Erb’s (2008) Fundamentals



Normal

EYELASHES:

1. Evenness of distribution and direction of curl.

Equal distribution; slightly thin lashes;

curls slightly outward.

Equal distribution; curls slightly outward.Kozier and Erb’s (2008) Fundamentals



Normal

EYELIDS:

1. Surface characteristics, position in relation to the cornea, ability to blink, frequency of blinking.

Skin is intact and closes symmetrically.

Involuntary blink present about 12 times in a minute.

Ski is intact; no discoloration; no

discharges; lids close symmetrically.

Approximately 15-20 involuntary blinks per

minute; bilateral blinking when lids are open, no visible sclera

above corneas are slightly covered.




Normal

CONJUNCTIVA:

1.Color, texture, and presence of lesions in the Bulbar conjunctiva

Transparent and capillaries are

prominent.

Transparent and capillaries sometimes

evident; sclera appears white

(yellowish in dark-skinned clients).




Normal

2. Color, texture, presence of lesions on the palpebral conjunctiva.

Shiny and smooth, pale red.

Shiny, smooth and pink to red in color.




Normal

SCLERA:

1.Color and clarity White in color. White.Kozier and Erb’s (2008) Fundamentals

Normal



CORNEA:

1.Clarity and textureTransparent, smooth, shiny; when the client blinks, the cornea is

touched.

Transparent, smooth, shiny; details of iris are visible. Client

blinks, the cornea is touched, indicating that the trigeminal

nerve is intact.Kozier and Erb’s (2008) Fundamentals



Normal

IRIS:

1.Color and shapeDark brown in color,

oval

Color varies, oval and flat




Normal

PUPILS:

1.Color,shape, symmetry Black in color; smooth

and round

Black in color; normally 3-7 mm in

diameter, round, smooth borders.




Normal

2. Light reaction and accommodation.

Illuminated and non-illuminated pupil

constricts.Color black and both

eyes are with the same equally rounded

structure.

Illuminated and non-illuminated pupil

constricts.Kozier and Erb’s (2008) Fundamentals



Normal

VISUAL ACUITY:

1.Near vision Client can read newsprint.

Able to read newsprint.




Normal

2.Distant vision Client can see far objects

20/20 on the Snellen chart




Normal

LACRIMAL GLAND, LACRIMAL SAC, NASOLACRIMAL DUCT:

1. Inspect and palpate the lacrimal gland and duct.

No edema or tearingNo edema or tearing




Normal

EXTRAOCULAR MUSCLES:

1.Eye alignment and coordination

Eyes are coordinated, aligned and parallel

with each other.

AlignmentKozier and Erb’s (2008) Fundamentals



Normal

VISUAL FIELDS:

1.Peripheral vision Client can see objects in periphery.

When looking straight ahead, client can see objects in periphery.




Normal

EARS

AURICLES:

1. Color, symmetry and position. Color is the same with

Color is the same with the skin in the face; Normal

the skin in the face; symmetrical and

aligned with the eyes.

auricle aligned with the outer canthus of

the eye, about 10 degrees from vertical.Kozier and Erb’s (2008) Fundamentals



2. Texture, Elasticity and areas for tenderness.

Movable, firm, recoils readily when

distorted.

Movable, firm and not tender, pinna recoils after it is

folded.Kozier and Erb’s (2008) Fundamentals



Normal

EXTERNAL EAR CANAL:

1. Cerumen, presence of skin lesions, pus or blood.

With ear wax or cerumen; no

presence of pus or blood.

Ear wax, no lesions, pus or blood.




Normal

NOSE:

1. Shape, size, color, flaring, or discharge. Symmetric, straight,

uniform in color

Symmetric, straight, uniform in color, no discharges or flaring.




Normal

2. Presence of redness, swelling, growths or discharge of the Nasal Cavities.

Mucosa is pink; no redness or swelling;

no presence of lesions.

Pink mucosa, clear, watery discharge; no

lesions.Kozier and Erb’s (2008) Fundamentals



Normal

3. Nasal Septum. Intact and aligned medially

Nasal septum is intact and aligned medially



Normal


4.Patency test or the nasal cavities

Air exchanges with ease.

Air moves freely as the client breathes through the nares.




Normal

5. Tenderness, masses, displacement of the bone and cartilage.

No tenderness and displacement

No tenderness and displacement.




Normal

SINUSES:

1.Tenderness No tenderness Not tender.Kozier and Erb’s (2008) Fundamentals



Normal

SINUSES (front and maxillary)1. Tenderness No tenderness No tenderness noted on

palpation.(www.nursingcrib.com)

Normal

MOUTHI. Lips:1. Symmetry, color, contour and texture

Symmetrical, uniform pinkish to brown in color, dry lips, smooth

• Symmetry in contour• Uniform pinkish• Moist lips• Smooth(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.499)

Abnormal. Dry lips indicate fluid deficit.

II. Buccal Mucosa:1. Color, Moisture, Texture and presence of lesions

Pinkish color, soft and moist

• Uniform in color• Soft and moist• Smooth and elastic

Normal

texture(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.499)

III. Teeth:1. Color, number, condition, presence of dentures

20 teeth, smooth, white

• 20 primary teeth• Smooth• Shiny tooth enamel• Smooth and intact dentures(http://www.colgate.com)

Normal

2. Color and condition of gums

Pink gums, moist, firm

• Pink gums• Moist• Firm texture to gums• No retraction of gums(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.499)

Normal

IV. Tongue:1. Color and texture of mouth floor and frenulum

Reddish color, veins prominent, and smooth texture

• Smooth tongue base with prominent veins(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.501)

Normal

2. Position, color, texture, movement and check the base of the tongue

Tongue is located at the center, pink color, moist, papillae prominent and moves freely

• Central position• Pink color• Moist• Slightly rough• Thin whitish coating• Smooth lateral margins• No lesions• Raised papillae• Moves freely• No tenderness(Kozier, Barbara(2002), Fundamentals of Nursing

Normal

5th edition: Addison-Wesley Publishing Company, p.501)

3. Presence of nodules, lumps or excoriated areas

No tenderness, no palpable nodule or lumps

• Smooth with no palpable nodules(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.501)

Normal

V. Palates and Uvula:1. Color, shape, texture and presence of bony prominence

Soft palate is pale, pink in color, smooth while hard palate is pink in color and normal texture

• Pink color• Moist• Soft palate• Light pink hard palate• More regular texture(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.502)

Normal

2. Position and mobility of uvula

Medially aligned • Position in midline of soft palate(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.502)

Normal

VI. Oropharynx and Tonsils1. Color and texture Pink and smooth • Pink and smooth

posterior wallNormal

2. Size, color and discharge

No tonsipharyngeal congestion

• Pink• Smooth• No discharge

Normal

NECKI. Lymph Nodes:1. Tenderness No tenderness • No tenderness

(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.505)

Normal

II. Trachea:1. Placement Midmost with

equal spaces on both sides

• Central placement in the midline of the neck• Spaces are equal in both sides(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.506)

Normal

III. Thyroid Glands1. Inspect for symmetry and visible masses

No visible masses • Not visible in inspection(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.506)

Normal

2. Smoothness and areas of enlargements

No engorgement • Lobes may be not palpated. If palpated lobes are small, smooth and rise freely when swallowing.(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.507)

Normal

Body part Actual findings Norms and Standards Analysis and Interpretation

THORAX:I. Posterior Thorax:1. Shape, symmetry, diameter of anterior thorax to transverse diameter

Transverse diameter is twice the anteroposterior diameter, symmetrical, intact skin

• Anteroposterior to transverse diameter is in ratio of 1.2• Chest symmetric(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.513)

Normal

2. Spinal alignment Spine is aligned • Spine is vertically Normal

aligned(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.513)

3. Temperature, tenderness and masses

Uniform in temperature, absence of tenderness and masses

• Uniform in temperature• No tenderness• No masses(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.513)

Normal

4. Respiratory excursion Symmetrical chest expansion, the thumbs move apart an equal distance during assessment

• Full and chest expansion(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.514)

Normal

5. Vocal fremitus Symmetrical in both sides

• Bilateral symmetry of vocal fremitus• Fremitus is most clearly heard at the apex of the lungs(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.514)

Normal

6. Percussion Resonance except in the scapulae

• Percussion notes resonate, except over the scapula. Lowest point of resonance is at the diaphragm(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.515)

Normal

7. Auscultation Clear breath sounds

• Clear breaths sound(Kozier, Barbara(2002), Fundamentals of Nursing

Normal


II. Anterior Thorax1. Breathing patterns Effortless

respiration• Quiet• Rhytmic and effortless respirations(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.447)

Normal

2. Temperature, tenderness and masses

Uniform in temperature with no tenderness /masses

• Uniform in temperature• No tenderness• No masses(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.513)

Normal

3. Auscultation of the trachea

Loud bronchial sound and long phase of expiration

• Bronchial sound is houd, “harsh” sounds that has short inspiratory phase(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.517)

Normal

4. Auscultation of the anterior thorax

Vesicular sounds heard at inspiration, bronchovesicular sounds heard in both expiration and inspiration

• Vesicular sound has soft intensity, low pitched, “gentle sighing” and is best heard on inspiration which about 2.5 times longer than expiratory phase• Bronchovesicular sound is moderate-pitched “blowing” sound and has equal inspiratory and expiratory phases(Kozier, Barbara(2002), Fundamentals of Nursing

Normal


CARDIOVASCULARI. Carotid Arteries:1. Palpation of the carotid artery

Symmetric pulse • Symmetric pulse volumes• Full pulsations• Thrusting quality(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.523)

Normal

2. Auscultation of the carotid artery

No heard pulsations

• No sound heard on auscultation (Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.524)

Normal

II. Jugular Veins:1. Inspection of the jugular veins

Not visible No visible mass or lumps.

Symmetrical No jugular venous

distension(www.nursingcrib.com)

Normal

BREAST AND AXILLAE1. Size, symmetry, contour, and shape

Symmetrical contour, no dimpling

• Females: rounded shape, slightly unequal in size, generally symmetric(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.529)

Normal

2. Skin of the breast Uniform in color, smooth and intact

• Skin uniform in color, smooth and intact(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-

Normal

Wesley Publishing Company, p.529)

3. Size, shape, position, color, surface, characteristics and any mass or lesions of the areola

Round and the same on both sides, light pink, no mass or lesions

• Rounded or oval, with same color, (Color varies from light pink to dark brown depending on race).(www.nursingcrib.com)

Normal

4. Size, shape, position, color, discharge, and lesions of the nipples

No abnormal nipple discharge

• Rounded, everted, same size and equal in color• No discharge except for breastfeeding females(www.nursingcrib.com)

Normal

5. Palpation of breast for masses and tenderness

No palpable mass, no tenderness

• No lumps or masses are palpable.•No tenderness upon palpation.•No discharges from the nipples.(www.nursingcrib.com)

Normal

ABDOMEN1. Skin integrity No blemishes,

uniform in color, with abdominal incision brought by surgery

• Unblemished skin, uniform in color(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.534)

Normal

2. Abdominal contour Slight globular abdomen

• Contour (flat, rounded, scapoid)(www.nursingcrib.com)

Normal

3. Enlargement of the liver or spleen

Absent • No evidence of enlarge(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.534)

Normal

4. Symmetry of contour Symmetric • Symmetric contour(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing

Normal

Company, p.535)5. Abdominal movements associated with respirations, peristalsis or aortic pulsations

Symmetric • Symmetric movements caused by respiration• Visible peristalsis in very lean people• Aortic pulsation in thin persons at epigastric area(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.535)

Normal

6. Vascular patterns No visible pattern • No visible vascular pattern(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.533)

Normal

7. Bowel sounds, vascular sounds, peritoneal friction rubs of abdomen

Audible bowel sounds, no bruits

present

• Audible bowel sounds• Absence of arterial bruits(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.535)

Normal

8. Percussion of each abdominal quadrant

Tympanic in the stomach area, dull over the

organs

• Tympany over the stomach and gas-filled bowels, dullness especially over the liver and spleen or full bladder(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.533)

Normal

9. Palpation of all four quadrants

No tenderness, abdomen is

relaxed without intense tension

• No tenderness, relaxed abdomen with smooth consistent tension(Kozier, Barbara(2002),

Normal

Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.535)

MUSCULOSKELETAL SYSTEMMuscles:1. Muscle size and symmetry (arm, thigh, calf)

Equal size on both sides and symmetrical

• Equal size on both side of the body(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.540)

Normal

2. Contractures of muscles or tendons

Absent • No contractures(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.540)

Normal

3. Muscle fasciculation or tremors

Absent • No muscle fasciculation or tremors(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.540)

Normal

4. Tonicity of muscles Firm • Normally firm(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.541)

Normal

5. Strengths of muscles Symmetrical on both sides

• Equal strengths of both sides of the body(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.541)

Normal

Bones:1. Normal structures and deformities

No deformities • No deformities(Kozier, Barbara(2002), Fundamentals of Nursing

Normal


2. Presence of edema or tenderness

No edema • No tenderness or swelling(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.541)

Normal

Joints:1. Presence of joint swelling

None • No swelling(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.542)

Normal

2. Palpation for tenderness, smoothness of movement of movement, swelling, crepitation and presence of nodules

Absence of tenderness, swelling or crepitation or presence of nodules

• No tenderness, swelling or crepitation or presence of nodules• joints move smoothly(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.542)

Normal

Range of motion:Upper Extremities:1. Shoulder and scapula Movable within

range of motion• Varies in accordance with the person’s genetic make up and degree of physical activity(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.542)

Normal2. Elbows3. Hands

Lower Extremities:1. Acetabulum or inguinal area

Movable within range of motion

• Varies in accordance with the person’s genetic make up and degree of physical activity

Normal

2. Popliteal3. Ankles

(Kozier, Barbara(2002), Fundamentals of Nursing 5th edition: Addison-Wesley Publishing Company, p.542)

VII. LABORATORY AND DIAGNOSTIC EXAMINATION RESULTS

URINALYSIS

Macroscopic

Results Normal Analysis and Interpretation

Color Yellow Yellow Normal

Character Hazy Clear Deviation from normal. Cloudy urine or urine with a high level of sediment may be present in cases of urinary tract infection. People who have had bladder surgery may also have cloudy urine due to colonization of bacteria within the bladder.

ph 6.0 5.0 – 9.0 Normal

Protein (-) (-) Normal

Specific Gravity 1.030 1.005 to 1.065 Normal

Bilirubin (-) (-) Normal

Urobilinogen Normal Normal Normal

Nitrite (-) (-) Normal

Blood (-) (-) Normal

Ketones (-) (-) Normal

Glucose (-) (-) Normal

Leukocytes +1 Negative Pyuria

HEMATOLOGY

Result 08/02/09

Results 08/04/09

Results 08/06/09

Results 08/07/09

Normal Values

Interpretation Analysis

RBC 4.76 x 10¹²/L

4.25 x 10¹²/L

- - 4.5-5.5 x 10¹²/L

Decreased. Red blood cells carry oxygen from the lungs to the rest of the body. They also carry carbon dioxide back to the lungs so it can be exhaled. If the RBC count is low (anemia), the body may not be getting the oxygen it needs.

Hemoglobin

11.80 g/dl

10.80 g/dl

12.70 g/dl

11.60 g/dl

12-14 g/dl

Decreased. Hemoglobin deficiency can be caused either by decrease amount of hemoglobin molecules as in anemia, or decreased ability of each molecule to bind oxygen at the same partial pressure of oxygen. In any case, hemoglobin deficiency decreases blood oxygen-carrying capacity.

Hematocrit

0.36 L/L

0.32 L/L

0.38 L/L

0.37 L/L

0.37-0.45 L/L

Normal

Platelet Count

257 x 10⁹⁄L

100 x 10⁹⁄L

78 x 10⁹⁄L

73 x 10⁹⁄L

160 -380 x 10⁹/L

Decreased. A low platelet count (called thrombocytopenia) refers to an abnormally low number of platelets, the particles in blood that help with clotting. As a result, blood does not clot normally. This is mainly caused by the

virus, where the body use too much platelets in response to the virus.

MCV 74.6 fl 75.0 fl 82-92 fl

Decreased. MCV refers to the size of each red blood cell. This usually signals anemia.

MCH 24.8 pg

25.4 pg

27-33 pg

Decreased. MCH refers to the concentration of hemoglobin in each red blood cell. This is usually signals anemia.

MCHC 33.2% 33.9% 32-38%

Normal

WBC 3.78 x 10¹²/L

2.46 x 10¹²/L

5.0-10.0 x 10¹²/L

Decreased. A low white blood cell count can be the result of infection, make an individual more susceptible to outside infections or allow multiplication of organisms within the body which would normally kept in check by a healthy immune system.

Differential - is the determination of the proportion of each of the types of white blood cells in sample of 100 white blood cells.

Eosinophils 0.01 0.03-0.05 Decreased. Decreased eosinophils indicate infection.

Segmenters 0.34 0.55-0.65 Decreased. It indicates infection.

Lymphocyte 0.44 0.25-0.35 Increased. It indicates infection.

SEROLOGY

Dengue blot IgG (-) IgM (+)

Remarks: Dengue NSI Antigent (-)

IgG: immunoglobulin that protects against viruses, bacteria, and toxins. It is more for a secondary response. Thus specific IgG antibodies against infections indicate past exposure and probable immunity.

IgM: the major component in a primary immune response. IgM antibodies are indicators of an active infection.

X. ECOLOGIC MODEL

A. Hypothesis

The patient’s condition is caused by the variety of factors which have interrelationship to one another. The factors that contribute to the occurrence of having Dengue-H fever are the host, the agent and the environment. Among the three factors mentioned earlier, the environmental factors which include physical (climate) and biological (living environment of man consisting of animal, plants and fellow human beings) environment tremendously contribute in the occurrence and causation of the disease.

B. Predisposing Factors

HOST

1. Filipino

-Dengue fever is a mosquito-borne disease that is endemic in the Philippines.

2. Reinfected for the second time

-More severe illness may occur in some people. These people may be experiencing dengue fever for the first time. However, in some cases a person may have already had dengue at one time, recovered, and then is reinfected with the virus. In these cases, the first infection teaches the immune system to recognize the presence of arbovirus. When the immune cells encounter the virus during later infections, the immune system over-reacts.

AGENT

1. Dengue Virus Type 1

-Dengue fever is caused by any of four strains (1, 2, 3 and 4) of dengue virus. The virus is transmitted to humans by the Aedes mosquito; it is not capable of human to human transmission. At least two species of this mosquito, aegypti and Aedes albopictus, serve as vector of the virus of the virus. In the Philippines, the main vector is Aedes aegypti.

ENVIRONMENT

1. Physical Environment

a. Climate

-During rainy season the incidence of contracting dengue is higher because its mosquito vector is able to breed more rapidly during this period.

A

H

E

2. Biologic Environment

a. Vector- Aedes aegypti

- Serves as a transmitter of virus to human.

3. As verbalized by the patient’s father “There is stag water in front of the house and also there is a nearby river”.

C. Ecologic Model

LEVEL MODEL

Analysis:

Lever model emphasizes the environmental factors. In the patient’s case, the environmental aspect contributes a lot to the occurrence of the disease specifically the physical and the biological environement. The characteristics of the agent and the host are greatly influenced by the environemental condition. In the figure above, we can see that illness has taken place. If the environment is suitable for the agent’s growth and reproduction, then we can say that there is a direct relationship between the two said factors. Therefore, the environment factors cause the agent to grow and reproduce.

D. Conclusion and Recommendations

Environmental factors contributed a lot in the occurrence and causation of the disease. Therefore, the focus of care is more on prevention of complications that might happen if the disease is left untreated. Health teachings specifically ways on how to prevent the spread of disease should be instructed to the patient. Importance of clean environment should be emphasized.

XIII. DISCHARGE PLAN

M – edication

Intake of appropriate vitamin supplement and diuretics to increase protection mechanism of the immune system and decreases renal vascular resistance and may increase renal blood flow, respectively.

E – conomic

The use of nonpharmacotherapy such as drinking plenty of water will promote increase plasma in blood to increase immunity and hydration, proper hygiene and promotion of cleanliness at home and work area.

T – reatment

Management of such condition would be through hydration and doing control measures to eliminate vector by promoting cleanliness in the environment through proper disposal of rubber tires, changing of water of lower vases once a week, destruction of breeding places of mosquito and residual spraying with insecticides.

H – ygiene

Advise support people to follow proper body hygiene for the client and to maintain cleanliness on surroundings. In addition, encourage to apply lotion having mosquito repellant property. This would prevent additional cases of DHF.

O – ut Patient/ Follow-up

Any odd signs such as fever, petechiae, recurrence of fever,etc. must be immediately reported to the physician.

D – iet

Instruct to eat foods that are low fat, low fiber, non-irritating and non-carbonated.

S – pirituality

Encourage to pray.

EVALUATION

CONCLUSION

The patient in this study had undergone supportive and symptomatic management. Proper nursing care such as water therapy and administration of prescribed drugs were done to promote comfort and repression of symptoms. Hygiene was also strictly implemented to avoid risk for further infection. Nursing assistance was also given to help him in her activities of daily living.

Health teaching is a very important role on the part of the nurses. This is of great significance to the knowledge deficit of patients and/or support people regarding health and illness.

Recommendation

Strict compliance to the medical treatment, health teachings and medical check-up is advised. With proper nutrition and conformity to the medications & therapy, recovery would be easier and faster.

case study (dhf)

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