SLH-CNP-DENGUE (2).docx_0

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an2netlazarCENTRO ESCOLAR

UNIVERSITYCity of Malolos, Bulacan

NURSING DEPARTMENT

COMPREHENSIVE

NURSING CAREPLANSAN LAZARO HOSPITAL


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currently no availablevaccine, but outbreaks can be prevented by reducing the habitat

and number of mosquitoes, and limiting exposure to bites.

Health officials last year warned of a possible epidemic of dengue fever in Asia. The

World Health Organization said in July that 2007 could be on a par with 1998, when

nearly 1,500 people died in the region from the disease. The Philippines has recorded

nearly 40,000 cases of dengue fever in the first 11 months of the year, the health

department said. The department has said about 290 people had died from dengue

fever in the first 10 months of the year,

Treatment of acute dengue is supportive, using either oral or intravenous rehydration for

mild or moderate disease, and blood transfusions for more severe cases. Rates of

infection have increased dramatically over the last 50 years with around 50100 million

people infected yearly. A global disease, dengue is currently endemic in more than

110 countries with 2.5 billion people living in areas where it is prevalent. Early

descriptions of the condition date from 1779, and its viral cause and the transmission

were elucidated in the early 20th century. Dengue has become a worldwide problem

since the Second World War.
http://en.wikipedia.org/wiki/Vaccinehttp://en.wikipedia.org/wiki/Vaccinehttp://en.wikipedia.org/wiki/Rehydrationhttp://en.wikipedia.org/wiki/Blood_transfusionhttp://en.wikipedia.org/wiki/Endemic_(epidemiology)http://en.wikipedia.org/wiki/World_War_IIhttp://en.wikipedia.org/wiki/Vaccinehttp://en.wikipedia.org/wiki/Rehydrationhttp://en.wikipedia.org/wiki/Blood_transfusionhttp://en.wikipedia.org/wiki/Endemic_(epidemiology)http://en.wikipedia.org/wiki/World_War_II


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C. HISTORY OF PRESENT ILLNESSJanuary 7, 2011, Friday, 8 days Prior to Admission, the patient is at Quaipo, he

attended a mass like he always do every Friday. After the mass, he ate fishballs at the

street and drink water.

January 8, 2011, 7 days prior to admission, the patient experience increased in

body temperature. He managed it by drinking Paracetamol every 4 hours.

January 9, 2011, the patient is at Luneta because he will participate in the feast

of Nazareno, the patient is a devotee that is why even though he is not feeling well, he

still attended the parade. And on that day, according to the patient, it also rained.

January 10, 2011, the patient decided to seek consultation to a clinic at San Jose

Del Monte Bulacan, he was advised to have a Complete Blood Count, and the result

says that he has a decrease in platelet count. The doctor prescribed Paracetamol every

4 hours and Oral rehydration solution for 3 days.1 day prior to admission, the patient is afebrile, with epigastric pain and (+) LBM,

he seeks consultation at the Jose Reyes Hospital and then decided to transfer at San

Lazaro Hospital and was admitted. Admission Diagnosis was Typhoid Fever vs Dengue

F


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Before the onset of the disease, the patients sleep pattern is, he is sleeping early

in the evening like between 7:00 PM-08:00PM and wakes up about 4:00 in the morning.

According to him, he was not able to sleep after that. After the onset of the disease,

there is an alteration in his sleeping pattern because of the discomfort he is

experiencing.

I. SOCIAL DATA

The patient has good relationship with his family. They are able to bond and be

happy sometimes although there are problems. His support system is his children that

are sometimes giving him money to be able to use for their daily living.

J. EDUCATIONAL HISTORY

The patient is a highschool graduate.

K. OCCUPATIONAL HISTORY

The patient is a tricycle driver, and since the onset of the disease, he was not


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II. Skin

The patient skin is dark brown in color. Skin is warm to touch with a

temperature of 36.7C, slightly dry in skin folds. There is a decreased in skin

turgor and dry skin.

There is a decreased in skin turgor and dry skin because of decreased fluid

in the body of the patient related dehydration because of the disease process.

III. Hair

The hair of the patient is black, evenly distributed and covers the whole

scalp. The hair is not oily, thick and shiny. No infections or infestations noted, the

amount of body hair is variable.

IV. Nail

The shape of the nail is convex curvature 160 degrees, the texture is

smooth and has intact epidermis. The nail bed is pinkish in color and the nails

color prompt return in less than 3 seconds while performing the blanch test


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external ear canal inspection revels that there is a minimal amount of cerumen,

no lesions, pus or blood present.

For the nose, the external nose is symmetric and straight, the septum is

straight, the color of the nose is as the same as the skin color. The sinuses are

not tender and air moves freely while client breathe through the nares.

VI. Mouth and oropharynx

For the mouth assessment reveals that the lips is pinkish, moist and

smooth, the teeth is well aligned with no filling. The gums are pinkish, moist and

no swelling. The tongue is slightly rough on top and symmetrical; the frenulum is

straight and is at the midline. The mouth floor is pinkish and moist. The hard and

soft palate is pinkish and moist. The uvula is symmetrical, the tonsils are

symmetrical, no discharge and non-inflamed. The gag reflex is present. No

bleeding gums, no sore tongue, dry mouth or frequent sore throats.

VII. Neck


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XI. Abdomen

The patient is not experiencing LBM, not vomiting. The patient is not

experiencing trouble in swallowing, heartburn, nausea. The patient is not

experiencing abdominal pain, food intolerance, or excessive belching or passing

of gas. No gallbladder trouble and hepatitis.

XII. Musculoskeletal

The clients muscle, joints, and bones are not swelling. Not tender uponpalpation.

XIII. Gross motor

The client able to perform passive ROM exercise, and is ambulatory He can sit,

d t d d h lk t f t Th li t bl t id tif d f


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PERSON GORDON APPROACH

PSYCHOLOGICALI. Self perception Self-concept pattern:

QUESTIONS CLIENTS RESPONSE INTERPRETATION

Description of self The patient verbalized that

he is kind, simple, and isreligious.

Patient has a positive self

concept. Self-concept isones mental image ofoneself. The client haspositive self-concept whichare better able too developand maintain interpersonalrelationships.(KOZIERp.1003)

Feeling towards self The patient stated that heis friendly and kind. Andthat he is a positive thinker.

Patient is a positive thinker.Self-esteem is ones

judgment of ones worth,that is, the clientsstandards and


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Support system Siblings The family was able todistribute the roles for each

family member. Role is aset of expectations abouthow the person occupyingone position behaves.(KOZIER p.1006)

Family form andstructure

He is living with his wife;some of his children havetheir own family already.Their support system is herdaughter. Both of them areinvolve in decision making.

Sufficiency income Income of the family is justright for their needs, it issufficient.

The family was able to findways to be able to supplytheir needs with a limitedincome. The greater thenumber of resources aperson has and uses, themore positive the effect onthe self-concept.(KOZIER p.1007)

Structuralcharacteristics (space,privacy, conducivenessduring mealtime)

The patient stated that theyhave sufficient space athome and its comfortable.

Individual resources shouldhave internal and externalstructures. (KOZIERp.1007)

Perceptions feeling The patient describes their The foundation of self


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being.

IV. Cognitive perceptual

Hearing difficulty The patient stated that hedo not have any hearingdifficulty.

Normal sense of hearing.Sensory deficit is impairedreception, perception, orboth, of one or more of thesenses. (KOZIER p.982)

Visual problems The patient stated that hedo not experience anyvisual changes.

Blindness and deafness aresensory deficits.


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Satisfaction with ones life The patient stated that he issatisfied in his life. He

accepts whatever the Lordgives to him.

Although, the patient andhis family has problems, he

is still satisfied with hislife.The sense of identityhas provides a person witha feeling of continuity andunity of personality. Theindividual sees himself asunique (kozier p.1005)

Things and personalvalues; held as important

The patient verbalized thathis family and their health isimportant to him. And alsohis faith to the Lord.

Patient was able to statepersons he held asimportant. The greater thenumber of the resources aperson has and uses, themore positive the effect onthe self concept (kozier

p.1005)

Family/social values thatinfluenced ones life;

The patient stated that hismother influenced him forbeing religious

Ones value are largelyinfluenced by the family andculture (kozier p 1007)


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Bowel elimination pattern The patient verbalized that he movesbowel regularly, before onset of disease,

he defecate at least once a day usually inthe morning. He is not experiencing anydiscomfort during elimination. After theonset of disease, his bowel elimination isaffected because he is experiencing aLBM, his bowel elimination at this time isat least 3x or more a day and is loose.

Urinary elimination pattern Before admission the patients urinaryelimination is at least 5x a day because heis drinking water often. During admission,the patient still has increase in urinaryelimination because of the increase intakeof oral fluids plus the intravenous line toprevent dehydration.

Use of aids The patient do not have difficulty in his


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Sufficiency of energy forcompleting desired

activities

The patient has sufficientenergy in completing his

activities of daily livingbefore his confinement.

Vigorous physical activity isnot always needed to

achievepositive result.(Fundamentals of Nursing5th edition by Taylor, page1117)

Exercise Program The patient is walking everymorning which he considersas his exercise everyday.

Lack of exercise, inactivity,or immobility related toillness, or

injury place a person athigh risk for serious healthproblems.Immobility can affect themajor body systems. Likethe benefits, a


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Circadian rhythms, time,

duration of sleep

The patient sleeps at 8pm,

sometimes 9pm and wakesup at 4 am, and was notable to sleep again so thepatient just start hisactivities of the day.

For no known reason,

8hours of sleep at night hasbeen the acceptedstandard for adults despiteobvious variations seen inthe general population. It isimportant that a personfollows a pattern of rest thatmaintains well being. Many

factors affect a personsability to rest illnesses andvarious life situations thatcauses physiological stresstends to disturb sleep.(Kozier et.al, Fundamentalsof Nursing 7thed. Page 1169-1170).

Use of supportive devices The client stated that hedoes not use supportiveaids to sleep.

Sleep onset problems,dreams and earlyawakenings

The patient experiencedifficulty in sleeping, hecannot sleep continuouslysince he was admitted atthe hospital.


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Allergies The patient does not haveany allergies to any food or

drug.

Allergies should beassessed to be able to

determine which food anddrug is apppropriate for histreatment plan.

Skin integrity

Changes in body

temperature

The clients skin is slightlydry.

The patient is afebrile.

The patients temperature isin normal state.

OXYGENATION

Tolerance with dailyactivities

The patient was able toperform activities of dailyliving without any difficultyon breathing or shortnessof breath.

Oxygenation status shouldbe assessed to determinethe need of oxygen therapywhen needed especiallyduring continuous works.


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Food/fluid preference The patient stated that, heis not eating pork meats,and foods rich in uric acidlike monggo beans andalso fat-rich foods. He isusually eating fried fish athoise.

According to the foodpyramid, the patient wasable to eat right foods thatis needed by the body, hewas able to eat foods inmoderation. An adequatefood intake consists ofbalance essentials

nutrients:water, carbohydrates, fats,proteins, vitamins andminerals. Habitsabout eating are affected bymany factors like financial


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Degree of appetite and

what seems to stimulateand dampen it

Delicious smell of food

often stimulate the patientsappetite, and when he seesmeat, it dampens hisappetite.

II. CASE DESCRIPTIONDIAGNOSTIC PROCEDURES

Hematology

It is a screening test used to diagnose and manage numerous diseases. The

results can reflect problems with fluid volume/ loss of blood. This test can reveal

problems with fluid volume/ loss of blood. The test can reveal problems with red blood

cell production and destruction or help diagnose infections, allergies, and problem with

blood clotting.

Nursing Responsibilities:


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The CBC provides valuable information about the blood and to some extent

the bone marrow, which is the blood-forming tissue. The CBC is used for the

following purposes:

as a preoperative test to ensure both adequate oxygen carrying capacity

and hemostasis

to identify persons who may have an infection

to diagnose anemia

to identify acute and chronic illness, bleeding tendencies, and white blood

cell disorders such as leukemia

to monitor treatment for anemia and other blood diseases

to determine the effects of chemotherapy and radiation therapy on blood

cell production

How Test is performed:

Blood is drawn from a vein, usually from the inside of the elbow or the back of the

hand The puncture site is cleaned with antiseptic An elastic band is placed around the


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01/16/11 01/15/11

WBCRBCHemoglobinHematocritMCVMCHMCHCPlatelet

RDWNeutrophilLymphocyteEosinophilMonocyteBasophils

18.824.4812.2837.5883.8227.3832.67309

15.178.611.11

35.61.7

16.734.0411.6

35.5888.0928.7232.6277

12.8479.112.71.261

4.8-10.8 10^9/L4.7-6.1 10^12/L

13-17 g/L40-52 %82-98 fl

28-33 pg33-36 10^9/L150-400 %

11.4-14.0 %40-70 %19-48 %2-8 %3-9 %0-5 %

All cell type is wnormal range exceptwhite blood cells whicincrease in number may indicate presencinfection.


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SGOT/AST 15.00 0.00-31.00 u/L NORMAL

SGPT/AST 11.00 0.00-41.00 u/L NORMAL

Alk. 326.00 53.00-128.00 u/L Increase in normal valuesAlkaline in blood

Phosphatase --- --- ----


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III. DRUG STUDY

Brand name/Generic name

Dosage,Route,

Administration

Action Indication Side Effect Contraindication Nursing considerat


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Acetaminophen(Paracetamol)

Adult and child:>12 yrs old:PO/RECT 325-650 mg q4hprn, max4g/dayChild: PO 10-

15 mg/kg q4h

May block the painimpulsesperipherally thatoccur in responseto inhibition ofprostaglandinsynthesis; does not

possess anti-inflammatoryproperties;antipyretic actionresults frominhibition ofprostaglandins inthe CNS(hypothalamicheat-regulatingcenter)

Symptomatic relief ofpain and fever. Reliefof headache,toothache, backpain,dysmenorrheal,myalgias,neuralgias, etc.

Analgesics and antipyretic for patientshypersensitive toaspirin

Hema: leukopenina,neutropenia,hemolytic anemia,thrombocytopenia,pancytopeniaCNS: stimulations,drwosiness

GI: nausea,vomiting, abdominalpain, hepatotxicity,hepatic seizureInteg: rash, urticariaGU: renal failure

Hypersensitivity,intolerance totartazine (yellowdye #5), alcohol,table sugar,saccharin,depending on the

product.

Assess for liverfunction studies: ASALT, bil irubin,creatinine prior totherapy

Renal function stud

Administer with foomilk to decreasegastric symptom ifneeded

Teach patient not texcess recommendosage

Instruct patient sigof toxicity to drug:nausea, vomiting,abdominal pain, anrefer to the prescri

Notify prescriber ofpain or fever lastinover 3 days.


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Dosage,Route,

Administration

Action Indication Side Effect Contraindication Nursing considerat


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Cefixime 10 mg 3caps BID

Renal dose:CCr 21-60ml/min give 75% of dose,CCr 50 kg or>12 yrs: Pouse adultdosageChild


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Dosage, Route,Administration

Action Indication Side Effect Contraindication Nursing consideration


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Furosemide 20mg IV STAT

Adult: O 20-80mg/day in AM maygive another dose in6hr up to 600 mg/dayIM/IV: 20-40 mg,increased 20mg q2h

until desired responseChild: PO/IM/IV:2mg/kg may increaseby 1-2 mg/kg q6h-8hup to 6 mg/kg

Inhibitsreabsorption ofsodium andchloride at proximaland distal tubuleand in the loop of

Henle.

Pulmonary edema,edema in CHF, liverdisease, nephroticsyndrome, ascites,hypertension

CNS:headache,fatigue,weakness,vertigo,paresthesia

CV:orthostatichypotension,chest painEENT: loss ofhearing, earpain, tinnitusELECT:hypokalemia,hypochloremic alkalosis,hypomagnes

emia,hyperurecemia,hypocalcemia,hyponatremia, metabolicalkalosis

Hypersensitivity tosulfonamides,anuria,hypovelomia,infants, lactation,electrolyte

depletion

Assess for signs ofmetabolic alkalosis:drowsiness,restlessness

Signs of hypokalemiapostural hypotension

malaise, fatigue, legcramps, tachycardia

Instruct patient to eatfoods rich inpotassium

Assess for vital signsbefore administration

Laboratory studiesbefore administrationof medication


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Dosage, Route,Administration

Action Indication Side Effect Contraindication Nursing consideration


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Amlodipine5mg/tab OD

Angina:Adult: PO 5-10 mg qdHypertension:Adult: PO 5 mg qdinitially, max 10mg/day

Inhibits calcium ioninflux across cellmembrane duringcardiacdepolarization;produces relaxation

of coronaryvascular smoothmuscle, peripheralvascular smoothmuscle, dilatescoronary vasculararteries, increasemyocardial oxygendelivery in patientswith vasospasticangina.

Chronic stableangina pectoris,hypertension,vasospastic angina(Prinzmetalsangina); may

coadminister withotherantihypertensives,antianginals.

CV:dysrhythmia,edema,bradycardia,hypotension,palpitations,

syncope, AVblockGI: nausea,vomiting,diarrhea,gastric upset,constipation,abdominalcramps,anorexiaGU: nocturia,polyuria

INTEG: rah,pruritus,urticaria, hairlossCNS:headache,fatigue,dizziness,anxiety,depression

Sick sinussyndrome, 2nd or 3rd

degree heart block,hypotension lessthan 90mmHgsystolic,

hypersensitivity

Assess for vital signsbefore administrationof the medication

Record the I&O

Instruct the patient totake the drug as

prescribed, do notdouble or skip dose

Instruct patient toavoid hazardousactivities untilstabilized on drug,dizziness is no longea problem

Instruct patient tochange positionslowly to prevent

orthostatichypotension

Instruct patient tocontinue good oralhygiene.

III. NURSING CARE PLAN


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Cues Diagnosis Scientificexplanation

Planning Implementation Rationale


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Subjective:

Nilalagnat atnanghihina poako. as verbalizedby the patient.

Objective: Weakness andirritability.

flushed skin

Skin Warm totouch.

Febrile

Restlessness.

Vital Signs takenas follows:(Admitting vitalsigns)T: 38.1CP: 80 bpmR: 17 cpmBP: 130/80 mmHg

Hyperthermiarelated toincreasedmetabolicrate and diseaseprocess.

Aedes Aegypti

Dengue Virus

IgG adheres tothe platelet

(initiates

destructionof the platelet)

thrombocytopenia(50,000/mm3 or

less)

Increased potentialfor hemorrhage

(epistaxis)

stimulates

intenseinflammatory

response

petechial rash,high fever,headache

Short-term goal:After 4 hours ofnursing interventionsthe patient will be ableto:

List ways on howto maintain body

temperature Demonstrate

techniques on howto lower bodytemperature

Take medicationsthat can lowerbody temperature.

Long-term goalAfter 4 days ofnursing interventionsthe patient will be ableto maintain core bodytemperature withinnormal range.

Independent:

Establish rapport with thepatient and patients relative

Note chronological anddevelopmental age

Monitor temperature

Monitor BP

Monitor heart rate andrhythm.

Monitor respirations

Note presence or absenceof sweating

Advise increase fluid intake.

Encourage TSB.

Loosen clothing

To gain the trust andcooperation

Children are moresusceptible to heatstroke

To have baseline data.

Central hypertension orperipheral/posturalhypotension may occur.

Dysrhythmias and ECGchanges are common.

Hyperventilation may bepresent.

Evaporation is decreasedby environmental factors ofhigh humidity.

To prevent dehydration.

To promote heat loss byevaporation andconduction.

To promote heat loss byradiation and conduction.

Aftnuintpato:


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Provide cool environmentand/or fan.

Put local ice packs or wettowels areas of high bloodflow, especially groin and

axillae.

Provide hypothermiablankets.

Maintain bed rest

Monitor and record I and O

Dependent:

Administer meds asordered, antipyretics and/orantibiotics.

Administer fluidreplacement as indicated bythe physician.

Interdependent:

Provide high-calorie diet,tube feeding, parenteralnutrition.

To promote heat loss byconvection.

To promote heat loss.

To minimize shivering.

To reduce metabolicdemands/oxygenconsumption.

For baseline data.

To lower temperature.

To support circulatingvolume and tissueperfusion.

To meet increasedmetabolic demands.


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Cues Diagnosis Scientificexplanation

Planning Implementation Rationale


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Subjective:

Objective:

Weakness andirritability.

Restlessness.

Vital Signs takenas follows:(Admitting vitalsigns)T: 38.1CP: 80 bpmR: 17 cpmBP: 130/80 mmHg

Injury, risk forhemorrhagerelated to alteredclotting factor.

Aedes Aegypti

Dengue Virus

IgG adheres tothe platelet

(initiates

destructionof the platelet)

thrombocytopenia(50,000/mm3 or

less)

Increased potentialfor hemorrhage

(epistaxis)

stimulates

intenseinflammatory

response

petechial rash,high fever,headache

After 4 hrs. Of nursinginterventions, theclient will be able todemonstratebehaviors that reducethe risk for bleeding.

Independent:

Perform thoroughassessments regardingsafety issues when planningfor client care.

Assess for signsand symptoms ofG.I bleeding.Check for secretions.Observe colorand consistency of stools orvomitus.

Position the client onupright position with headtilted slightly forward.

Using your fingers applypressure to the sides of thenose.

Apply nasal pack or coldcompress.

Observe forpresence of

petechiae, ecchymosis,bleeding from one more

Failure to accuratelyassess and intervene orrefer these issues canplace the client at needlessrisk and creates negligenceissues for healthcare

practitioner.

The G.I tract(esophagus andrectum) is themost usualsource of bleeding of itsmucosal fragility.

To minimize the amountof blood pressure on nasal

vessels and to keep bloodmoving forward, not backto the nasopharynx.

To minimize or stopbleeding.

To minimize or stopbleeding.

Sub-acute disseminated

Intravascular coagulation(DIC) maydevelop

Anuintclieto dbered

for

T


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sites.

Monitor pulse,Blood pressure.

Note changes inmentation and level ofconsciousness.

Avoid rectalTemperature.

Encourage use of softtoothbrush, avoidingstrainingfor stool, and forceful nose

blowing.

Use small needles forinjections. Apply pressure tovenipuncture sites for longerthan usual.

Recommend avoidance ofaspirin containing products.

Dependent:

Administer medications and

infusions as prescribed andby using 5 rights system

secondary to alteredclotting factors. An increase inpulse with decreasedBlood pressure canindicateloss of circulating blood

volume. Changes mayIndicate cerebral perfusionsecondary to hypovolemia,hypoxemia.

Rectal vessels are mostvulnerable to rupture.

In the presence ofclotting factor disturbances,minimal trauma can cause

mucosal bleeding.

Minimizes damage totissues, reducing risk forbleeding and hematoma.

Prolongs coagulation,potentiating risk of hemorrhage.

To treat the underlying

cause of the disease.


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(right patient, rightmedication, right route, rightdose,right time)

Interdependent:

Monitor Hgb andHct and clotting factors.

Indicators of anemia,activebleeding, or impendingcomplications.


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