Case study: Dengue

TABLE OF CONTENTS
1. Introduction 2. Objectives of the study -general objectives -specific objectives 3. Theoretical framework 4. Nursing health history -demographic data -history of present illness -past medical history -family history -social history -environmental history -genogram 5. Gordons level of functioning 6. Physical assessment 7. Laboratory exams 8. Anatomy and physiology 9. Pathophysiology 10. medical/surgical intervention 11. Drug study 12.nursing care plan 12. Discharge plan 12. Bibliography

INTRODUCTION
This case is a about a 13 years old boy who was admitted at Capitol medical center on September 21, 2012 with a chief complaint of fever and was diagnosed with dengue.

Dengue fever is a disease cause by a family of viruses that are transmitted by Aedes mosquitoes. This mosquito transmits the disease by biting an infected person and then biting someone else. The mosquitoes that transmit dengue live among human and breeds in discarded tires, flower pots, old drums and water storage containers close to human dwellings.

Unlike the mosquitoes that cause malaria, dengue mosquitoes bit during the day. Symptoms such as headache, fever, exhaustion, severe joint and muscle pain, swollen glands (lymphadenopathy), and rash. The presence (the "dengue triad") of fever, rash, and headache (and other pains) is particularly characteristic of dengue fever

MANILA, Philippines -- Global warming may have contributed to a 43 percent rise in the number of dengue cases in the Philippines for the first half of the year. The biggest increase in the country was seen in Metro Manila, where there was an almost 200 percent increase. "The increase in the number of dengue cases may be attributed to the constantly changing climate brought by global warming as well as congestion in urban areas," World Health Organization officials earlier this year warned climate change was increasing the incidence of dengue fever and other infectious diseases in the country. There is no known cure or vaccine for dengue fever, which is transmitted by the white-spotted mosquito.

OBJECTIVES OF THE STUDY

General objectives

the main goal of the study is for me to have an additional knowledge related to pneumonia and to develop my skills in assessing a patient with pneumonia

Specific objectives

interpret data gathered from the patient identify and explain etiology of the underlying condition

discuss the anatomy and physiology of the related disease trace the pathopysiology of the disease explain how the theoretical framework relates to the patients present condition discuss the Gordons pattern of functioning and physical assessment obtained classify the drugs being taken by the patient carry out interventions that were discussed in the nursing care plan

THEORETICAL FRAMEWORKS
Environmental theory
Florence nightingale was born on May 12 1820. She was the founder of modern nursing and the first nursing theorist. Also known as "The Lady with the Lamp She was the first to propose nursing required specific education and training. Her contribution during Crimean war is well-known.

Assumptions of nightingales theory

Natural laws Mankind can achieve perfection Nursing is a calling Nursing is an art and a science Nursing is achieved through environmental alteration Nursing requires a specific educational base Nursing is distinct and separate from medicine

Nightingales canons: major concepts

Ventilation and warming Light, Noise Cleanliness of rooms/walls Health of houses Bed and bedding Personal cleanliness Variety Chattering hopes and advices Taking food. What food?

Nightingale's documents contain her philosophical assumptions and beliefs regarding all elements found in the metaparadigm of nursing. These can be formed into a conceptual model that has great utility in the practice setting and offers a framework for research conceptualization

4-digm

Nursing Nursing is different from medicine and the goal of nursing is to place the patient in the best possible condition for nature to act. Nursing is the "activities that promote health (as outlined in canons) which occur in any caregiving situation. They can be done by anyone." Person People are multidimensional, composed of biological, psychological, social and spiritual components. Health Health is not only to be well, but to be able to use well every power we have. Disease is considered as dys-ease or the absence of comfort. Environment "Poor or difficult environments led to poor health and disease". "Environment could be altered to improve conditions so that the natural laws would allow healing to occur."

In a relation to the patient, In the case of the patient wherein she manifested dengue, it can be correlated with the theory of nightingale where in the environment of the patient is a factor leading to recovery, having a clean environment, well organized house, nurturing environment and taking fruits and vegetables, the body could repair itself.

NURSING HEALTH HISTORY

A. personal history Name: MT Age: 13 Address: cordero 8th avenue grace park Caloocan city Birth day: July 25, 1999 Sex: male Civil status: single Religion: roman Catholic Attending physician: Dr. Naidas Admission diagnosis: systemic viral illness ruled out dengue fever Admission date: September 21, 2012 Chief complaint: Fever B. history of present illness 4 days prior to admission patient had colds. 1 day prior to admission patient was noted to be febrile at (40. O C) paracetamol was given and the patient consulted a local clinic and was diagnosed with acute tonsillopharyngitis. Co-amoxiclav was prescribe patient was able to take medication for 3 days C. past medical history Patient was healthy but he had been admitted to the hospital several times before. His last admission was on February 2012 due to scarlet fever. And he also has bronchial asthma. And his vaccination was unrecalled D. personal/social history Patient is now in grade 7. He lives with his mother, father and his siblings. The patient is a Nonsmoker and Non-alcoholic drinker. He was also inclined to sports like basketball, and sometimes he plays badminton for past time. He loves to eat chicken and pork but he hates vegetables. E. Environmental history Patient lives in an urban area which is not crowded but somehow semi-polluted F. Family health history Patients father who resides in Caloocan together with his Family doesnt have any history of other diseases aside from hypertension which were treated by medications prescribed by their physician. Similarly, they have also stated that the family is not sports-inclined and has not practiced much of their active lifestyle. Usually they spend their time at work and at home watching television and movies and enjoy occasional drinking. On the other hand, her mother who grew up in Caloocan had a history of diabetes and asthma.

GORDONS PATTERN OF FUNCTIONING

Pattern 1. Health perception maintenance Before hospitalization The patient takes vitamins and but doesnt eat vegetable. The patient have regular checkups yearly with his physician During hospitalization The client health is good the fever resided, but the rashes on his skin were still there. And his family informed the nurse on duty when the clients temp. Increased. Hes on DFA and NDCF, still eats 3 times a day. And he had an on-going IV fluid. And takes 600 cc of water per day The client still urinates 4 to 5 times a day and defecated once a day Analysis The patient can manage his health, he informed the nurse whenever he feels something wrong, and it really helps the medical staffs to treat him.

2. Nutritional metabolic pattern

Eat 3 meals per day and sometimes take midnight snacks. And consume 5-6 glasses of water per day The patient defecates once a day without any discomfort and it is well formed. he usually urinates 4 or 5 times a day without any pain or discomfort Have no regular exercise but he plays basketball and badminton. The client sleeps 6 to 7 hrs without difficulties. Usually sleeps 11pm to 5 am.

3. Elimination pattern

There are no many changes in patients nutritional and metabolic pattern. And the client has proper diet and fluid intake There are no many changes in patients elimination pattern

4. Activity and exercise pattern

5. Sleep and rest pattern

6. Cognitive and perceptual pattern

Patient is alert and well oriented

The patient lies on bed most of the time, and not allowed to mobilize as much due his IV. The client has no choice but to sleep and rest, but he has difficulty of sleeping because of the nurses and doctors rounds Patients easily understands and cooperates well

There is minimal activities due to his hospitalization The clients sleeping routine has been changed. Patients sleep was disturbed because of the nurses and doctors rounds There are no changes in clients cognitive and perceptual pattern. The client can express himself but doesnt communicates well The patients is irritable because of her condition, but can cooperate with the others The patient is independent but

7. Self-perception and selfmaintenance

The patient is serious and family centered

8. Role relationship pattern

The patient is the youngest son. And he

The patient is not that approachable but very cooperative, he is always surrounded by his family The patient is always accompanied by his

lives with his mother, father and brothers 9. Sexuality reproductive 10. Coping/stress tolerance the patient is not sexually active The patient doesnt encounter much problem, and his always happy The client is a roman catholic. he goes to mass every Sunday with his family, and pray every night before going to sleep

11. Values and beliefs

oldest brother, and his relatives visits once in awhile The patient doesnt perform any sexual activities the patient seems bored and somehow unhappy, and he plays laptop to entertain himself The clients still have time to pray every night together with his brother

somehow depends on his brother due to his condition There is still no changes in the patients sexuality reproduction The client is not comfortable because he is hospitalized and wanted to go home soon The client is religious and even though he is hospitalized he had time pray

PHYSICAL ASSESSMENT
General findings height weight temperature Pulse rate Respiratory rate Blood pressure Normal 45-53 45.3-49.8 36.5-37.5 60-100 12-20 90/60 to 130/90 Findings 52 54 36.6 80 20 100/70 Analysis Height is in the normal range Weight is not in the normal range Temperature is in the normal range Pulse rate is in the normal range Respiratory rate is in the normal range Blood pressure is in the normal range

Area assessed A. Skin

Color

Technique

Normal findings

Findings

Analysis

Inspection

Moisture Temperature

Light brown, tanned skin (may vary according to race) Inspection/palpation Skin normally dry Palpation Normally warm

Light brown in color, has pink rashes Normally dry Warm to touch

Due to dengue

Normal Normal

Texture Turgor Skin appendages Nails

Palpation Palpation

Smooth and soft Skin snaps back immediately Transparent, smooth and convex Pinkish Firm Evenly distributed Black to light brown Warm to touch and tenderness Pinkish and slightly rough Perform w/o any difficulty Perform without any difficulty Generally round

smooth and soft Skin snaps back immediately Transparent, smooth and convex Pinkish Firm Evenly distributed black

Normal Normal

Inspection

Normal

Nails bed Nails base Hair distribution Color Upper extremities Arms Palms and dorsal surface Shoulders Elbows Skull Eyes Eyes Eyebrows

inspection Inspection Inspection Inspection

Normal Normal Normal Normal Normal Normal Normal

Palpation/inspection Palpation/inspection

Warm to touch and tenderness Pinkish and slightly rough Perform w/o any difficulty Perform without any difficulty Generally round

Inspection Inspection Inspection

Normal Normal Normal

Inspection Inspection Non protruding Symmetrical in size, extension, hair texture and movement Evenly distributed Non protruding Symmetrical in size, extension, hair texture and movement Evenly distributed

Normal Normal

Eyelashes Eyelids Conjunctiva

Inspection Inspection Same color as skin Same color as skin Inspection Transparent with light pink color Color white Free of Lesions, discharge or inflammation Client normally hears words when whispered. Nose in the Transparent with light pink color Color white Free of Lesions, discharge or inflammation Client normally hears words when whispered. Nose in the

Normal Normal Normal

Sclera Ears

Inspection Inspection

Normal Normal

Hearing acuity

Inspection

Normal

Nose

Inspection

Normal

midline; no discharges; no bone or cartilage deviation noted. neck Inspection/palpation No visible mass or lumps; symmetrical; no jugular venous distension. Lymph nodes inspection May not be palpable; nontender IF PALPABLE; less than 1cm in size. Thyroid Inspection Normally nonpalpable; no nodules palpable Thorax Lungs Auscultation Illustrate voluntary sound Cardiovascular Inspection Pulse visible; no lift or heaves. Abdomen inspection

midline; no discharges; no bone or cartilage deviation noted. Normal No visible mass or lumps; symmetrical; no jugular venous distension. Normal May not be palpable; nontender IF PALPABLE; less than 1cm in size. Normal Normally nonpalpable; no nodules palpable

Normal Illustrate voluntary sound Normal Pulse visible; no lift or heaves. Normal Skin color is Uniform color to uniform, no the rest of the lesions; some may skin have presence of striae or scars Equal in size; no Equal in size; no edema; no edema; no crepitus crepitus

lower extremities

Inspection

Normal

LABORATORY EXAM HEMATOLOGY Latest report September 23, 2012

Test Hemoglobin Actual findings 163 g/l Normal findings 135-160 Analysis/interpretation The no. of hemoglobin increased indication of poor oxygen supply normal The no. of erythrocytes increased indicates that the red blood cells are carrying less oxygen than normal Normal Normal Normal The no. of WBC count decreased indication of vulnerable to potential serious infection which is dengue The no. of neutrophils decreased resulted to underlying condition which is dengue that affects the cell production The no. of lymphocytes increased because of the infection Normal Normal Normal

Hematocrit Erythrocytes

0.48 5.59 1012/l

0.40-0.48 4.5-5.0

MCV MCH MCHC Total WBC

87.70 fl 29.20 pg 33.30 g/dl 3.4 10g/l

80-96 27-33 33-36 5.0-10.0

Nuetrophils

0.37

0.55-0.65

Lymphocytes

0.53

0.25-0.40

Monocytes Stabs Platelet count

0.06 0.04 230

0.02-0.06 0.01-0.05 150-440

Previous September 22, 2012

Test Hemoglobin Hematocrit Erythrocytes MCV MCH MCHC Total WBC

Actual findings 146 0.44 4.98 87.30 29.30 33.60 4.1

Normal findings 135-160 0.40-0.48 4.5-5.0 80-96 27-33 33-36 5.0-10.0

Nuetrophils lymphocytes Monocytes Stabs Platelet count

0.65 0.25 0.06 0.03 213

0.55-0.65 0.25-0.40 0.02-0.06 0.01-0.05 150-440

Analysis/interpretation Normal Normal Normal Normal Normal Normal The no. of WBC count decreased indication of vulnerable to potential serious infection which is dengue Normal Normal Normal Normal Normal

ANATOMY AND PHYSIOLOGY BLOOD

Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells.

PHYSICAL CHARACTERISTIC
Bright red (oxygenated) dark red/purplish (unoxygenated). Much more dense than pure water. pH range from 7.35 to 7.45 (slightly alkaline). Slightly warmer than body temperature 38.Celsius. Typical volume in adult male 5-6 liters typical volume in adult female 4-5 liters typically 8% of body weight

COMPONENTS OF BLOOD
The blood is considered to be the only fluid tissue in the body. It is complex connective tissue in which formed elements are suspended in a nonliving fluid matrix called plasma. The plasma is the liquid part of the blood and is approximately 90% water. 3 formed elements in the blood 1. Erythrocytes- responsible for blood gas transport 2. Leukocytes defends body from infection or disease 3. Platelets- needed for normal blood clotting
(in this case, platelets are the ones mostly affected by the dengue virus so this will be our focus)

Blood cell formation/hematopoieses (platelets)

Hematopoieses occurs in the red bone marrow or the myeloid tissue. Red bone marrow is found chiefly in flat bones like the skull, pelvis, the ribs, sternum, humerus and femur. All of the formed elements arise from a common type of stem cell called hemocytoblast which resides in the red bone marrow

The hemocytoblast stem cells develop into lymphoid or myeloid stem cells. Myeloid stem cells by then will developed as platelets or other formed elements depending on the response of the changing body needs and different stimuli. Like any other formed elements in the blood, platelet production is stimulated by the hormones. The hormone thrombopoietin accelerates the production of platelets but only little is known about how this process is regulated

PLATELETS Platelets are not cells in a strict sense. They are fragments of bizarre multinucleated cells of megakaryocytes. They appear as darkly stained and irregularly shaped. The nominal platelet count is 150,000 500,000 per cubic millimeter.

PHYSIOLOGY OF PLATELETS Platelets are responsible for normal blood clotting. If we are going to live without it, a single cut would lead us out to death. There is a process called hemostasis wherein platelets have a major role. Hemostasis means stooping of bleeding. It happens when a blood vessel breaks or injured. Hemostasis occurs in three major phases which occur in rapid sequence. 1. Vascular spasms occur the immediate response of the body to blood vessel injury

2. Platelet plug forms when the endothelium is broken, the collagen fibers are exposed that leads to clinging of the platelets to the damage site and making them sticky. Platelets released more chemicals that attract more platelets to the site of damage. 3. Coagulation event occurs A. Injured tissues released tissue factors (TF), substances that plays an important role in clotting. B. PF3 which is a phospholipid, coats the surfaces of the platelets, interacts with the TF, Vit K, calcium ions and other protein clotting factor C. Prothrombin activator for conversion of prothrombin to thrombin which is an enzyme. D. Thrombin joins fibrinogen proteins to form long hair like molecules of insoluble fibrin which forma netlike meshworks that traps RBCs and forms the basis of the clot.

PATHOPHYSIOLOGY (BOOK-BASED)

Predisposing factors Geographical area: Caloocan city

Precipitating factors Environmental conditions (stagnant water as breeding sites) Dengue carrier mosquitoes Activity (student)

Replication of virus in mosquitoes salivary glands

Bite to skin from dengue carrier mosquito (itchiness and redness at the bite area)

Dengue virus is inoculated in the blood with 8 -14 days incubation period

Virus disseminates rapidly in the blood stimulating WBCs and B lymphocytes and produces antibodies and macrophages

Macrophages performs phagocytosis; dengue virus replicates within the cells, antibodies attach to viral antigents

Entry to the spleen

Release of cytokines and other platelet activating factors that stimulates WBCs and pyrogen release

Entry to the bone marrow

DENGUE s/s: High grade fever Flushed skin Headache Pink rashes on the skin

If Treated: HYDRATION: IV infusion; increased fluid intake Drug therapy: antipyretic (Paracetamol) Careful monitoring condition

If not treated: Complications such: Intense bleeding Severe hypertension Pulmonary edema Shock Liver cirrhosis

RECOVERY

DEATH

DRUG STUDY
DRUG Paracetamol (biogesic) 500mg/tab 1 tab PRN MECHANISM OF ACTION
Produce analgesia by blocking pain impulses by inhibiting prostaglandin synthesis in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relief fever through central action in the hypothalamic heat regulating center.

INDICATION
Relief of fever, minor aches and pains

CONTRAINDICATION
Anemia, cardiac and pulmonary disease. Hepatic or severe renal disease

SIDE EFFECTS
Allergic skin reactions and GI disturbances

NURSING RESPONSIBILITIES
Assess for allergy Reassess the Pts vital signs

NURSING CARE PLAN

ASSESSMENT Subjective: Ang init ko po as verbalized by the patient Objective: -flush skin -skin is warm to touch V/s taken as follows: Temp: 38.2 PR-80 RR-20 BP-120/80 DIAGNOSIS Hyperthermia related to dengue PLANNING Short term goal: After 30 mins of nursing intervention the patient will maintain core temperature within the normal range with a temp: of 36.5-37.5 INTERVENTION Independent: -Establish rapport RATIONALE EVALUATION Short term goal: After 30 mins of nursing intervention the patient was maintained core temperature within the normal range with a temp: of 36.5-37.5

-to gain pts trust

-encourage pts to increase fluid intake

-to prevent dehydration because increased in temperature causes fluid loss such as sweating

-provided surface cooling such as TSB and removing of extra clothing

-to promote core cooling by helping reduced body temperature

Dependent: Give paracetamol (biogesic) as prescribe by the physician Paracetamol are classified as analgesics and antipyretics which acts on the hypothalamus to regulate normal body temperature

Discharge plan
DISCHARGE PLANNING
Discharge Planning Diet: Encourage nutritious foods like vegetables, meat and fruits.> Instruct the family members to give the client protein rich foods such as meat, fish, eggs and nuts, vitamin K rich foods such as green leafy vegetables, vit C rich foods(guava and tomatoes and other citrus fruits), carbohydrates rich food (breads and rice) Medications: Give acetaminophen in case the temperatures increases. Give oresol to replace fluid in the body. Remind to take the prescribed medicine, having a written reminder of the correct medication, time to take, and the right frequency of the medicine on the way home to establish assurance of medication compliance. Dont give aspirin and NSAIDs, they increase the risk of bleeding. Any medicines That decrease platelet count should be avoided. Exercise: Instruct to avoid excessive activities that may result to stress. Just advised to perform range of motions and repetitive body movements for promotion of optimum Treatment: Currently, no medications are available to treat dengue hemorrhagic fever. > Increased oral fluid intake. >Admission to an intensive care unit>Intravenous fluids and electrolytes >Oxygen therapy> Transfusions of blood and platelets as needed> Bed rest Out-Patient Follow-Up Care >Instruct the family members to have a check-up or to consult physician once a while to monitor patients condition and for detection of recurrences and other complications that may arise on to it. Health Teaching: (for prevention)> D- discuss the possible source of infection of the disease.> Eeducate the family/patient on how to eliminate those vectors.> N- Never stocked water in a container without cover.> G- Gallon, container and tires must have proper way of disposal.> U- Use insecticides at home to kill or reduce mosquito

Bibliography

books

Principles of Anatomy and Physiology Gerard J. Tortora (Author), Bryan H. Derrickson Laboratory Manual for Anatomy and Physiology[Spiral-Bound] Connie Allen (Author), Valerie Harper (Author)

Nurse's Pocket Guide (NANDA) 11th Edition

Google

http://www.scribd.com/doc/67121235/Dengue-Discharge-Plan http://www.google.com.ph/#hl=fil&sclient=psyab&q=discharge+plan+for+dengue&oq=discharge+plan+for+de&gs_l=serp.1.1.0l4.1547.11675.0 .14554.34.20.0.7.7.1.432.4670.0j1j9j3j3.16.0...0.0...1c.1.8kw1RkLWqF8&pbx=1&bav=on.2,or.r_g c.r_pw.r_qf.&fp=953ad84da23aef2c&biw=1024&bih=677