DENGUE FEVER

JANUARY 4, 2015
JIMENA, MARVI MAE T.

DENGUE FEVER
I.

Patient Profile
a. Demographics
Name: AMPA
Hospital Number: 00429469
Birthday: June 12, 2008
Age: 6 years old

Religion: Roman Catholic

Occupation: Student
Civil Status: Single
Educational Attainment: PreSchool

Measurements:
Weight: 20 kg
Height: 114 cm
Date and Time Taken: December 30, 2014, 0800H
Vital Signs:
Temperature: 36.6 C
Pulse Rate: 93 beats per minute

Respiratory Rate: 38 breaths per minute

Blood Pressure: 90/60 mmHg

b. Nursing Assessment
Neurological Assessment: Conscious, oriented to time, place and person. PERRLA, of
2mm, slightly pale conjunctivae, cornea transparent on both eyes. Muscle strength
at 5/5 on all extremities. Body malaise noted. Sensations intact, able to open mouth
fully, facial expressions appropriate to the situation, able to hear words at a distance
of 2 ft., gag reflex intact.
Cardiovascular/ Peripheral Assessment: Heart rate ranges from 88- 100 beats per
minute, regular in rhythm, no bruits heard upon auscultation. Pulse rate= 93 beats
per minute, normal, regular in rate and rhythm. Blood pressure = 90/60 mmHg,
capillary refill of 2 seconds on all extremities, pinkish nail beds, slightly pale
conjunctivae.
Respiratory Assessment: Chest Xray (12-29-14) result: Pneumonia vs atelectasis,
right lower lobe, Bilateral pelural effusion, more on the right interfissural fluid
minor. Respiratory rate of 38 breaths per minute, characterized by deep inhalation,
shallow exhalation, shortness of breath noted. Clear breath sounds upon
auscultation. Occasional cough and colds noted.
EENT Assessment: Pupils equally round, reactive to light and accomodation, 2-3mm,
slightly pale conjunctivae, cornea transparent on both eyes. Ears: symmetrical,
bilaterally equal in size and shape. Pain noted on the left ear, rated as 6/10. Minimal
fluid drainage noted. No internal and external injury distinguished, no foreign
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objects noted. Nose: midline; nasal mucosa: pink, moist, with vibrissae, no lesions or
polyps; nasal septum: intact and midline. Episode of minimal nose bleeding noted
after taking a shower, relived with applying cold compress. Throat: able to speak
clearly.
Gastrointestinal Assessment: On diet for age. Complained of abnominal pain rated
6/10. With normoactive bowel sounds of 8-15 cycles per minute in all 4 quadrants,
able to drink and tolerate oral fluids, able to consume 50% of meals served with
decreased appetite, dry lips noted, light yellow teeth, cavities on upper and lower
molars noted, moist oral mucosa, white plaques noted on the tongue, gingival and
mucosal pallor observed, with diet on no dark colored foods, defecated to moderate
amounts of soft yellowish stools. Abdominal Xray (12-29-14) revealed no significant
findings.
Genitourinary Assessment: Able to void freely to approximately 400 cc straw colred
urine all through out the shift. Grossly female genitalia, normal for age.
Integumentary Assessment: Skin is dry and intact, capillary refill of 2 seconds on all
extremities, good skin turgor of 2 seconds, pinkish nail beds, palmar pallor noted,
itchiness of macular rashes noted over extremities, trunk and back. There are also
multiple punctures sites due to blood extractions on the upper right extremity. Skin
color is fair and uniform in all body parts. Skin is warm to touch, smooth and shinny
in appearance.
Musculoskeletal Assessment: Can move freely, full ROM, 5/5 muscle strength on all
extremities. Generalized weakness noted.
Psychological/Social Assessment: Normal affect, appropriate response to situation.
Corresponds appropriately to questions asked.
Coping-Stress Tolerance Assessment: Usually verbalizes and cries when in pain. Her
support system is her family.
Rest and Sleep Assessment: Sleeps at long intervals at night and naps at daytime.
Values-Belief Assessment: No religion restrictions concerning treatment.
Intravenous Therapy Assessment: With IVF of D5LR 1L x 60cc/H at left metacarpal
vein, tightness noted, IV infusing well.
SAMPLE
Signs and Symptoms

Allergies
Medications

On and off fever, Macular rashes, Body malaise, Decreased

Appetite, Abdominal pain, Nose bleeding, Cough and Colds,
Ear pain.
No known allergies.
Probiotics (Protexin), Paracetamol, Omeprazole, Cetirizine,
Oxymetazoline, Brompheniramine, Cetaphil, Salbutamol,
Co-amoxiclav
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Past Medical History

Last Meal Taken
Events that Lead to
Admission

None
Last meal prior to admission was Biscuit and Water.
2 days prior to admission, patient experienced remittent
fever of undocumented temperature. The mother did TSB.
Patient was given Paracetamol 250mg/5ml, 5ml PO that
offered temporary relief. The mother noted the patients
general body malaise and provided the child frequent rest
periods, no medical consult was taken.
1 day prior to admission, there was persistence of the
above signs and symptoms. They consulted at the Asian
Medical Center and Hospital Emergency Department, CBC
with platelet count was done, revealed with normal
findings. Medication of Paracetamol was continued. They
were advised to come back for a repeat CBC the following
day.
4 hours prior to admission, there was persistence of
intermittent fever and abdominal pain. The mother claimed
the patient has decreased appetite. Macular rashes were
noted in the patients extremities, trunk and back. There
was an occasional non-productive cough and colds noted.
They had a follow-up check-up at Emergency Department,
requested for CBC and the result showed a decrease in
platelet, thus was advised for admission at the AHMC.

II.

Introduction

Dengue is the most important mosquito-borne viral disease that affects humans. Its
global impact is comparable to that of malaria, and an estimated 2.5 billion people live in areas
at risk for epidemic transmission. The disease is endemic in Africa, the Americas, and parts of
the Middle East, Asia, and the western Pacific. The frequency of dengue and its more severe
complicationsdengue hemorrhagic fever (DHF) and dengue shock syndromehas been
increasing dramatically since 1980. It is generally estimated that 50 to 100 million infections
occur annually, but recent data suggest that approximately 390 million dengue infections
occurred worldwide in 2010, including 96 million symptomatic illnesses. Dengue is caused by
any of four antigenically distinct virus serotypes (DEN-1, -2, -3, -4) of the genus Flavivirus.
Infection with any of the DENV serotypes may be asymptomatic in the majority of cases
or may result in a wide spectrum of clinical symptoms, ranging from a mild flu-like syndrome
(known as dengue fever [DF]) to the most severe forms of the disease, which are characterized
by coagulopathy, increased vascular fragility, and permeability (dengue hemorrhagic fever
[DHF]). The latter may progress to hypovolemic shock (dengue shock syndrome [DSS]). In Asia
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the risk of developing severe disease is greater in DENV-infected children (15 years) than in
adults. In contrast, in the Americas mainly the adult population is affected, resulting in mild
disease, although an increasing trend of cases progressing toward DHF/DSS has also been
observed in adults there.
In the Philippines, Dengue Fever is one of the major causes of hospitalizations. By
September 2011, the disease had already resulted in 285 deaths of children between 1 and 9
years of age. Fatalities for the 19 years-of-age cohort accounted for nearly 60% of deaths due
to dengue in 2011, which highlights the importance of early vaccination for young children in
endemic regions when a vaccine becomes available.
After recording a whopping 127,000 dengue fever cases in 2013, the Philippines
Department of Health (DOH) is reporting a dramatic decrease in cases of the mosquito borne
virus so far in 2014. Based on DOH surveillance reports from Jan. 1 to Aug. 16, 2014, the
Philippines have seen 49,591 cases, a decrease of some 61 percent.
In the latest statistics, according to the WHO-PRO Philippines, The National
Epidemiology Center of the Philippines' Department of Health reports 59,943 dengue cases
from January 1 to September 6, 2014. This is 59.57% lower compared to the same period last
year (148,279). Of the total cases, 10.47% came from Northern Mindanao (Region X), 9.6% from
CARAGA (Region XIII), 9.19% from Davao Region (Region 11). Next is from Region IV-A and ,
Region III, which are 8.93% and 8.01% respectively, to the overall figure. Majority of the
infected patients were 5 to 14 year old children (38.91% of the total cases), and more than half
were males (52.77%). 242 deaths (CFR 0.40%) was recorded since January 2014, and most of
them were children.
As a previously infected dengue patient myself, I have personally experienced the wrath
of the disease to my body and the stress it brought to my family. When I was diagnosed with
dengue when I was about nine, I was asymptomatic; the only problem was my platelet count,
decreasing every four hours, prompting my physician to have a blood transfusion on standby.
The experience left me with fear of hospitalization itself (and needle sticks!). Fortunately, the
infection did not result in hypotensive shock or hemorrhage and I made a full recovery.
I chose this case because it mirrors the current issue of dengue in children, though a
significant decrease was recorded, still, it is a major health problem we, Filipinos are dealing
with everyday with our family and community.
I utilized the patients chart for this study to obtain the history of present illness,
laboratory results, treatments made and the patients response and progress in the course of
the hospitalization. The major information provider was the mother, who is the primary care
provider.

Sources:
th

Mander, Douglas and Bennetts Principles and Practice on Infectious Diseases 8 Edition by John Bennett, Raphael Dolin and Martin Blaser
http://cmr.asm.org/content/22/4/564.full
http://www.denguematters.info/content/issue-7-dengue-philippines/
http://www.wpro.who.int/philippines/areas/communicable_diseases/dengue/continuation_dengue_area_page/en/
http://outbreaknewstoday.com/dengue-down-60-in-the-philippines-this-year-84443/

III.

Anatomy and Physiology

Dengue virus (DENV) belongs to the family FLAVIVIRIDAE, genus FLAVIVIRUS, and is
transmitted to humans by AEDES mosquitoes, mainly AEDES AEGYPTI. Based on neutralization
assay data, four serotypes (DENV-1, DENV-2, DENV-3, and DENV-4) can be distinguished.

In vitro data and autopsy studies suggest that three organ systems play an important
role in the pathogenesis of DHF/DSS: the immune system, the liver, and endothelial cell (EC)
linings of blood vessels.
Dengue Fever is manifested as an incapacitating disease in older children, adolescents,
and adults. It is characterized by the rapid onset of fever in combination with severe headache,
retro-orbital pain, myalgia, arthralgia, gastrointestinal discomfort, and usually rash. Minor
hemorrhagic manifestations may occur in the form of petechiae, epistaxis, and gingival
bleeding. Leukopenia is a common finding, whereas thrombocytopenia may occasionally be
observed in DF, especially in those with hemorrhagic signs.
Pathogenesis is linked to the host immune response, which is triggered by infection with
the dengue virus. Primary infection is usually benign in nature; however, secondary infection
with a different serotype or multiple infections with different serotypes may cause severe
infection that can be classified as either dengue haemorrhagic fever (DHF) or dengue shock
syndrome (DSS), depending on the clinical signs.
Clinical Manifestations:
1. Febrile or invasive stage (first 4 days) starts abruptly as high fever, abdominal pain &
headache; later, flushing which may be accompanied by vomiting, conjunctival infection & nose
bleeding.
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2. Toxic or hemorrhagic stage (4th 7th day) lowering of temperature, severe abdominal
pain, vomiting & frequent bleeding from tract (hematemesis & melena), unstable BP, narrowing
of pulse pressure, shock & death may occur.
3. Convalescence or Recovery (7 10 days) stable BP, appetite regain, generalized flushing w/
intervening areas of blanching.
The World Health Organization (WHO) classifies DHF in four grades (I to IV).

Grade I thrombocytopenia + hemoconcentration. Absence of spontaneous bleeding.

Grade II thrombocytopenia + hemoconcentration. Presence of spontaneous bleeding.

Grade III thrombocytopenia + hemoconcentration. Hemodynamic instability: filiform

pulse, narrowing of the pulse pressure, cold extremities, mental confusion.

Grade IV thrombocytopenia + hemoconcentration. Declared shock, patient pulseless

and with arterial blood pressure = 0 mmHg (dengue shock syndrome).

DHF is characterized by all the symptoms of DF, in combination with hemorrhagic

manifestations (positive tourniquet test or spontaneous bleeding), thrombocytopenia, and
evidence of increased vascular permeability (increased hemoconcentration or fluid effusion in
chest or abdominal cavities). The life-threatening DSS stage occurs at the time of or shortly
after defervescence, which is characterized by a rapid, weak pulse (20 mm Hg) or hypotension
with cold, clammy skin in the early stage of shock (grade III). If patients do not receive prompt
and appropriate treatment, a stage of profound shock may set in, in which pulse and blood
pressure become undetectable (grade IV), resulting in death within 12 to 36 h after onset of
shock.
It is worth noting that patients classified as having DHF and DSS have no generalized
edema; rather, a selective plasma leakage tends to occur in the pleural and abdominal cavities,
which is detectable by means of radiology or sonography. Ultrasonographic examinations have
revealed that plasma leakage occurs before defervescence or changes in hemoconcentration
become apparent.

IV.

Pathophysiology

V.

Medical and Nursing Management

Laboratory Exams
Diagnostic Tests
Complete blood count, Platelet, PT, and PTT Monitoring

Rationale
COMPLETE BLOOD COUNT. An essential component of a complete physical
examination, especially when performed on admission to a health-care
facility. Monitoring desired responses to therapy. Monitoring progression of
hematologic discrepancies caused by DENV.
WBC. It is especially helpful in the evaluation of the patient with infection. In
this case, low WBC is one of the symptoms of Dengue Fever.

Nursing Intervention
Nursing Responsibilities
Test preparation:
No fasting required.
Intervention:
BEFORE THE PROCEDURE.

RBC. This test is useful in classifying anemias. This may reflect if theres any
active bleeding.
Hgb. This is the amount of hemoglobin in a volume of blood. Hemoglobin is
the protein molecule within red blood cells that carries oxygen and gives
blood its red color. Along with RBC, is useful in classifying anemia.

Hct. Monitoring responses to fluid imbalances or to therapy for fluid

imbalances: A decreased Hct may indicate hemodilution. An increased Hct
may indicate dehydration. High Hct levels indicates high blood concentration
that would signify plasma leakage, a common complication in Dengue Fever.

Platelet Count. Identification of individuals who may be prone to

spontaneous bleeding, as indicated by a platelet count of less than 15,000 to
20,000 per cubic millimeter. Determination of effects of diseases and drugs
known to alter platelet levels such as Dengue Fever.

Prothrombin time. The prothrombin time (PT, pro time) test is used to
evaluate the extrinsic pathway of the coagulation sequence. To monitor
bleeding in Dengue Cases.

Explain to the client the purpose of the test the procedure including
the site from which the blood sample is likely to be obtained that
momentary discomfort may be experienced when the skin is pierced.
For children, a doll may be used as the patient for demonstration
purposes. A laboratory technicians equipment basket may hold the
childs attention during the actual procedure. For all clients,
encourage questions and verbalization of concerns about the
procedure, and provide a calm, reassuring environment and manner.
Because many drugs may affect the PT result, all medications taken
by the client should be noted.
If the individual is receiving anticoagulant therapy, the time and the
amount of the last dose should be noted.

THE PROCEDURE

A venipuncture is performed and the sample collected in a light-bluetopped tube.

Traumatic venipunctures and excessive agitation of the sample
should be avoided.

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are essentially the same as
for any study involving the collection of a peripheral blood sample.
Because the client may have a coagulation deficiency, maintain
digital pressure directly on the puncture site for 3 to 5 minutes after
the needle is withdrawn.
Inspect the site for excessive bruising after the procedure.

Partial Prothrombin time. The partial thromboplastin time (PTT) test is used
to evaluate the intrinsic and common pathways of the coagulation
sequence.

Chest Xray 12-69-14/ 1831H

Pneumonia vs atelectasis, Right lower lobe

Bilateral pleural effusion, more on the right interfissural fluid minor.

Abdoninal Xray

No significant findings.

Since Dengue Fever causes plasma leakage that can lead to pleural
effusion, the CXR may be a modality for evaluating the clinical course
of DHF and should be made during first week after the onset of
illness.

Test preparation:
You will need to remove any jewelry, eyeglasses, body piercings,
or other metal on your person. No fasting needed.
Intervention:
Maintain the patient on bed and assess for any discomfort.

Since DENV can infect the Liver, Spleen and other organs and causes
plasma leakage that can lead to ascites, the Abdoominal X ray may
be a modality for evaluating the clinical course of DHF and should be
made during first week after the onset of illness.

Test preparation:
You will need to remove any jewelry, eyeglasses, body piercings,
or other metal on your person. No fasting needed.
Intervention:
Maintain the patient on bed and assess for any discomfort.

Spot check

SpO2 stands for Peripheral capillary oxygen saturation. It is an

estimation of the oxygen saturation level.

96%-98%

Oxygen saturation is a term referring to the concentration of oxygen

in the blood. It measures the percentage of hemoglobin binding sites
in the bloodstream occupied by oxygen.

Test preparation:
Reinforce the explanation of the procedure to the patient.
Intervention:
Monitor pulse rate and patients condition.

With Dengue Fever, there may be a possible bleeding that causes

depletion of Hgb, therefore lowering the oxygen concentration in the
blood.

Nebulization

Restoring and maintaining mucus blanket continuity, hydrating dried

secretions, promoting secretion expectoration, humidifying inspired
oxygen, and delivering drugs for shortness of breath.

Test preparation:
Place the patient in sitting or high fowlers position.
Intervention:

Intravenous Fluid Therapy

D5LR 1L x 60cc/H

Fluid replacement is one of the most important supportive

management of dengue.

Position the patient appropriately, allowing optimal

ventilation.
Assess and record breath sounds, respiratory status, pulse
rate and other significant respiratory functions.
Teach patient the proper way of inhalation:
o Slow inhalation through the mouth via the
mouthpiece
o Short pause after the inspiration
o Slow and complete exhalation
o Some resting breaths before another deep
inhalation
Reassess patient status from breath sounds, respiratory
status, pulse rate and other significant respiratory
functions needed. Compare and record significant changes
and improvement. Refer if necessary
Attend to possible side effects and inhalation reactions

Intervention:
Identify acute situations: vomiting, diarrhea, bleeding or
febrile episodes
Monitor input and output.
Assess insertion site for infiltration/infection regulary.
Provide additional oral fluids as tolerated.
Calculate a daily fluid goal.
Compare current intake to fluid goal
Fluid regulation and documentation
Teach able individuals to use a urine color chart to monitor
hydration status.
Document a complete intake recording including hydration
habits.
Know volumes of fluid containers to accurately calculate
fluid consumption.

10

VI.

Drug Analysis

Drug Name

Generic Name:
co-amoxiclav
(amoxicillin and
clavulanate potassium)
Brand Name:
Augmentin
Class: BETA-LACTAM
ANTIBIOTIC;
AMINOPENICILLIN

Route, Dose
and
Frequency

Route:
Oral
Dose: 5 mL
Frequency:
every 12H

Indication

Infections caused by
susceptible betalactamaseproducing
organisms: Lower
respiratory tract
infections, acute
bacterial sinusitis,
community acquired
pneumonia,
otitis media,
sinusitis, skin and
skin structure
infections, and UTI.

Mechanism of Action

Side Effects

As a beta-lactam antibiotic,
GI: Diarrhea, nausea,
amoxicillin is bactericidal. It
vomiting.
inhibits the final stage of
bacterial cell wall synthesis by Skin: Rash, urticaria
binding with specific penicillinbinding proteins (PBPs) that
are located inside the bacterial
cell wall that leads to bacterial
cell lysis and death.
Effectiveness of ampicillin is
synergistic in combination with
clavulanic acid.
Clavulanic acid in combination
with ampicillin inhibits enzyme
(beta-lactamase) degradation
of amoxicillin and by synergism
extends both spectrum of
activity and bactericidal effect
of amoxicillin against many
strains of beta-lactamase
producing bacteria resistant to
amoxicillin alone.

Adverse Effects

Candidal vaginitis;
moderate increases in
serum ALT, AST;
hypersensitivity
reactions,
glomerulonephritis;
agranulocytosis (rare)

Nursing Considerations

Assessment & Drug Effects

Observe 10 Rights in administering
medications.
Give at the start of a meal to
minimize GI upset and enhance
absorption.
Agitate suspension well just before
administration of each dose.
Determine previous
hypersensitivity reactions to
penicillins, cephalosporins, and
other allergens prior to therapy.
Monitor for S&S of an urticarial
rash (usually occurring within a few
days after start of drug) suggestive
of a hypersensitivity reaction. If it
occurs, look for other signs of
hypersensitivity (fever, wheezing,
generalized itching, dyspnea), and
report to prescriber immediately.
Monitor for and report diarrhea,
which may indicate
pseudomembranous colitis.
Monitor lab tests: Baseline C&S
tests prior to initiation of therapy;
start drug pending results.
Patient & Family Education
Female patients should report
onset of symptoms of Candidal
vaginitis (e.g., moderate amount of
white, cheesy, nonodorous vaginal
discharge; vaginal inflammation and
itching; vulvar excoriation,
inflammation, burning, itching).
Therapy may have to be
discontinued.
Report onset of diarrhea and other
possible symptoms of
superinfection

11

Drug Name

Generic Name: Cetirizine

Brand Name: Virlix

Route, Dose
and
Frequency
Route: Oral
Dose: 5mL
Frequency:
Twice a day

Class: ANTIHISTAMINE;
H1-RECEPTOR
ANTAGONIST

Drug Name

Generic Name:
Bromoheniramine Maleate
Brand Name: Dimetapp
Class: ANTIHISTAMINE; H1RECEPTOR ANTAGONIST

Route, Dose
and
Frequency
Route: Oral
Dose: 5mL
Frequency:
Thrice a day

Indication

Urticaria.
Other uses: Seasonal
and perennial allergic
rhinitis and chronic
idiopathic

Indication

Symptomatic treatment
of allergic
manifestations. Also
used in various cough
mixtures and
antihistamine
decongestant cold
formulations.

Mechanism of Action

Cetirizine is a potent H1 receptor

antagonist and thus an
antihistamine without significant
anticholinergic or CNS activity. Low
lipophilicity combined with its H1receptor selectivity probably
accounts for its relative lack of
anticholinergic and sedative
properties.
Effectively treats allergic
rhinitis and chronic urticaria by
eliminating or reducing the local
and systemic effects of histamine
release.

Mechanism of Action

Antihistamine that competes with

histamine for H1-receptor sites on
effector cells in the bronchi and
bronchioles, thus blocking
histamine- mediated responses.
Effective against upper respiratory
symptoms and allergic
manifestations.

Side Effects

GI: Constipation,
diarrhea, dry mouth

Adverse Effects

Hypersensitivity

CNS: Drowsiness,
sedation, headache
depression
CV: Syncope

Nursing Considerations

Assessment & Drug Effects

Observe 10 Rights in administering
medications.
Monitor for drug interactions. As the
drug is highly protein bound, the
potential for interactions with other
protein-bound drugs exists.
Monitor for sedation, especially the
older adult, young children.
Patient & Family Education
Do not use in combination with OTC
antihistamines.
Do not engage in driving or other
hazardous activities, before experiencing
your responses to the drug.

Side Effects

CNS: Sedation,
drowsiness, dizziness,
headache, disturbed
coordination
GI: Dry mouth, throat,
and nose, stomach upset,
constipation.
Special Senses: Ringing or
buzzing in ears.
Skin:Rash;photosensitivity

Adverse Effects

Body as a Whole:
Hypersensitivity reaction

Nursing Considerations

Assessment & Drug Effects

Observe 10 Rights in administering medications.
Give at the start of a meal to minimize GI upset
and enhance absorption.
Drowsiness, sweating, transient hypotension,
and syncope may follow administration;
reaction to drug should be evaluated.
Keep prescriber informed.
Note: Older adultsand younger children tend to
be particularly susceptible to drugs sedative
effect, dizziness, and hypotension.
Most symptoms respond to reduction in
dosage.
Patient & Family Education
Do not use in combination with OTC
antihistamines.
Do not engage in driving or other hazardous
activities, before experiencing your responses
to the drug.
Acute hypersensitivity reaction can occur
within minutes to hours after drug ingestion.
Reaction is manifested by high fever, chills, and
possible development of ulcerations of mouth
and throat, pneumonia, and prostration.
Patient should seek medical attention
immediately.
Frequent rinses with warm water may relieve
dry mouth.
Do not take alcoholic beverages or other CNS
depressants (e.g., tranquilizers, sedatives, pain
or sleeping medicines) without consulting
prescriber.

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Drug Name

Generic Name: Oxymetazoline

Hydrochloride
Brand Name:Drixine
Class: NASAL PREPARATION;
DECONGESTANT

Route, Dose
and
Frequency

Indication

Route: Nasal
Spray
Dose: 1
spray per
nostril
Frequency:
Twice a day

Relief of nasal congestion in

a variety of allergic and infectious
disorders of the upper respiratory
tract; Also used as adjunct in
treatment and prevention of middle
ear infection by decreasing congestion
of Eustachian ostia.

Mechanism of Action

Sympathomimetic agent that acts

directly on alpha receptors of
sympathetic nervous system
resulting in relief of nasal
congestion. Constricts smaller
arterioles in nasal passages and has
prolonged decongestant effect.

Other uses: As nasal tampon to

facilitate intranasal examination or
before nasal surgery.

Drug Name

Generic Name: Lactobacillus casei,

Lactobacillus rhamnosus,
Streptococcus thermophilus,
Bifidobacterium breve,
Lactobacillus acidophilus,
Bifidobacterium infantis,
Lactobacillus bulgaricus,
fructooligosaccharide (FOS)
Brand Name:Protexin- Restore
Class: Probiotics

Route, Dose
and
Frequency
Route: Oral
Dose: 1
sachet mix
in 1 oz
water
Frequency:
Twice a day

Indication

As adjunct therapy for infant

pneumonia & URTI.
Food supplement for babies & young
childn 7 mth w/ digestive disorders
eg diarrhea associated w/ antibiotic
therapy, indigestion, lactose
intolerance, flatulence, bloating,
constipation. Enhancement of natural
resistance to intestinal infection,
bacterial/viral diarrhea. Prevention of
necrotizing enterocolitis
(NEC)/sepsis.

Side Effects

Special Senses:
Burning, stinging,
dryness of nasal
mucosa, sneezing.

Adverse Effects

Rebound
congestion.

Body as a Whole:
Headache,
lightheadedness,
drowsiness,
insomnia,
palpitations

Mechanism of Action

Side Effects

Adverse
Effects

These microorganisms replenish,

re-establish and maintain the
disrupted gut. Protexin Restore
promotes the mechanism of
competitive exclusion against
potential pathogenic bacteria,
efficient digestion and natural
immunity of the body. Protexin
Restore is designed for use:
During and after antibiotic
therapy to help prevent the
occurrence of antibiotic-associated
diarrhea
When introducing the infant to
pre-school when there is an
increased risk of infections such as
stomach infections or viruses such
as colds or flu.

No side effects
have been
reported, up to
the present time.

No adverse
have been
reported, up
to the present
time

Nursing Considerations

Assessment & Drug Effects

Observe 10 Rights in administering
medications.
Place spray nozzle in nostril without
occluding it and tilt head slightly
forward prior to instillation of spray;
instruct patient to sniff briskly during
administration.
Rinse dropper or spray tip in hot water
after each use to prevent
contamination of solution by nasal
secretions.
Monitor for S&S of excess use. If noted,
discuss possibility of rebound
congestion.
Patient & Family Education
Wash hands carefully after handling
oxymetazoline. Anisocoria (inequality
of pupil size, blurred vision) can
develop if eyes are rubbed with
contaminated fingers.
Do not to exceed recommended
dosage. Rebound congestion (chemical
rhinitis) may occur with prolonged or
excessive use.
Systemic effects can result from
swallowing excessive medication.

Nursing Considerations

Assessment & Drug Effects

Observe 10 Rights in administering
medications.
Do not administer if patient is
hypersensitivity to its components.
Monitor elimination patterns.

13

Route, Dose
and
Frequency

Drug Name

Generic Name:Omeprazole

Route: IV
Dose: 20mg
Frequency:
Once a day

Brand Name:Omepron
Class: PROTON PUMP
INHIBITOR; ANTISECRETORY
Therapeutic: ANTIULCER

Indication

As prophylaxis/prevention of possible
acidity and GI bleeding due to other
medication complications of DF.
Other uses:
Duodenal and gastric ulcer.
Gastroesophageal reflux disease
including severe erosive esophagitis (4 to
8 wk treatment).
Longterm treatment of pathologic
hypersecretory conditions such as
Zollinger-Ellison syndrome, multiple
endocrine adenomas, and systemic
mastocytosis.
In combination with clarithromycin to
treat duodenal ulcers associated with
Helicobacter pylori.
Dyspepsia occurring more than twice
weekly.

Mechanism of Action

An antisecretory compound that is a

gastric acid pump inhibitor. Suppresses
gastric acid secretion by inhibiting the
H+, K+-ATPase enzyme system [the
acid (proton H+) pump] in the parietal
cells. Suppresses gastric
acid secretion relieving gastrointestinal
distress and promoting ulcer healing.

Side Effects

CNS:Headache,
dizziness, fatigue.
GI: Diarrhea,
abdominal pain,
nausea, mild
transient increases
in liver function
tests.

Adverse Effects

trouble
awakening and
sleep
deprivation,
black tarry stool

Nursing Considerations

Assessment & Drug Effects

Observe 10 Rights in administering

medications.
Administer drug 30 minutes to 1 hr. before
meal.
Assess IV site for infiltration/infection.
Give slow IV push.
Observe for signs of GI bleeding.
Encourage verbalization of pain (PQRST).

Patient & Family Education

Urogenital:
Hematuria,
proteinuria

Skin: Rash

Report any changes in urinary elimination such

as pain or discomfort associated with urination,
or blood in urine.
Report severe diarrhea; drug may need to be
discontinued.

UNLABELED USES: Healing or prevention of

NSAID-related ulcers, stress gastritis
prophylaxis.

Drug Name

Generic Name:
albuterol/salbutamol
Brand Name: Ventolin
Class: Bronchodilator

Route, Dose
and
Frequency
Route:
Inhalation
Dose: 1 neb
Frequency:
Thrice a day

Indication

Mechanism of Action

Moderately selective beta2-adrenergic

agonist that acts prominently on smooth
muscles of trachea, bronchi, uterus, and
vascular supply to skeletal muscles.
Other Indication:
Inhibits histamine release by mast cells.
To relieve bronchospasm Produces bronchodilation by relaxing
associated with acute or smooth muscles of bronchial tree.
Bronchodilation decreases airway
chronic
resistance, facilitates mucous drainage,
asthma, bronchitis, or
and increases vital capacity.
other reversible
obstructive airway
diseases.
Also used to prevent
exercise-induced
bronchospasm.
For difficulty of
Breathing

Sie Effects

CNS: Tremor, anxiety,

nervousness,
restlessness, weakness,
headache
CV: Palpitation,
bradycardia,
reflex tachycardia.
Special Senses: Blurred
vision, dilated pupils
GI: Nausea, vomiting
Other: Muscle cramps,
hoarseness

Adverse Efects

Body as a Whole:
Hypersensitivity
reaction.

Nursing Considerations

Assessment & Drug Effects

convulsions,
hallucinations,
hypertension,
hypotension,

Observe 10 Rights in administering medications.

Instruct to sit upright or position bed in semi to high- Fowlers
postion.
Monitor therapeutic effectiveness, which is indicated by significant
subjective improvement in pulmonary function within 6090 min
after drug administration.
Monitor for: S&S of fine tremor in fingers, which may interfere with
precision handwork; CNS stimulation, particularly in children 26 y
(hyperactivity, excitement, nervousness, insomnia), tachycardia, GI
symptoms.
Consult prescriber about giving last albuterol dose several hours
before bedtime, if drug-induced insomnia is a problem.
Monitor lab tests: Periodic ABGs, pulmonary functions, and pulse
oximetry.
Do chestphysiotherapy thereafter.
Encourage patient to gargle after every inhalation.
Instruct deep breathing and coughing exercises.

Patient & Family Education

Avoid contact of inhalation drug with eyes.

Do not increase number of frequency of inhalations without advice
of prescriber.
Notify prescriber if albuterol fails to provide relief because this can
signify worsening of pulmonary function and a reevaluation of
condition/therapy may be indicated.
Note: Albuterol can causes dizziness or vertigo; take necessary
precautions.

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VII.

Nursing Care Plan

Assessment

Diagnosis

Objective cues:
- T= 38.1 degrees Celsius
-flushing, dry lips
-warm to touch
-malaise

Hyperthermia related to infectious

process.

Planning

Interventions

Short term goal:

Independent nursing interventions:

To be able to achieve normal body

temperature of 36.0-37.5 degrees
Celsius after 30 minutes to 1 hour
of intervention.

Monitor client temperaturedegree

and pattern. Note shaking chills or
profuse diaphoresis.

Long term goal:

Rationale

Evaluation
Short term goal:

Temperature of 102_F to 106_F

(38.9_C41.1_C) suggests acute
infectious disease process. Fever
pattern may aid in diagnosis.

Goal met. T= 36.6 degrees

Celsius.

Monitor environmental temperature.

Limit or add bed linens, as indicated.

Room temperature and linens should be

altered to maintain near-normal body
temperature.

Goal met. T= 36.0=37.0 degrees

Celsius since 12-27-14 up to
present.

Provide tepid sponge baths. Avoid use

of alcohol.

Tepid sponge baths may help reduce

fever. Note: Use of ice water or alcohol
may cause chills, actually elevating
temperature. Alcohol can also cause
skin dehydration.

Encourage increase oral fluid intake.

Monitor intake and output and provide
favorite beverage. Teach the
importance of maintaining adequate
fluid intake (at least 2,000 mL a day of
cool liquids unless contraindicated by
heart or kidney disease.

Fluid replacement. Helps to cool down

body temperature.

To be able to maintain normal body

temperature for the whole course
of hospitalization.

Long term goal:

Collaborative nursing interventions:

Administer prescribed medications as
To aid for faster recovery of patients
ordered. Paracetamol 250/5mL, 5ml PO condition.
Q4 PRN for T37.8 degrees Celsius.

15

Assessment

Objective Cues:
-Respiratory rate of 38-40 breaths per minute
(Tachypneic)
-Shortness of breath when lying flat.

Diagnosis

Ineffective breathing pattern

related to inadequate lung
expansion secondary to pleural
effusion.

Planning

Short term goal:

To be able to establish a
normal respiratory rate of
22-34 breaths per minute
after 30 minutes of nursing
intervention.

-O2 spot check 96-98%

Long term goal:

To be able to achieve and
maintain a normal and
effective respiratory pattern
with O2 normal saturation of
95%-100%, RR of 22-43
breaths per minute and be
free of cyanosis and other
signs or symptoms of hypoxia
after 24-48 hours.

Rationale

Independent nursing interventions:

Identify etiology or precipitating
factors, such as spontaneous
collapse, trauma, malignancy,
infection, and complication of
mechanical ventilation.
Evaluate respiratory function,
noting rapid or shallow respirations,
dyspnea, reports of air hunger,
development of cyanosis, and
changes in vital signs.

Chest X ray result:

Pneumonia vs atelectasis, Right lower lobe
Bilateral pleural effusion, more on the right interfissural
fluid minor

Intervention

Assess breathing patterns and

auscultate lung fields.

Evaluation

Short term goal:

Understanding the cause of the problems is
necessary for the choice of management.

Goal met. RR= 32 breaths

per minute.

Respiratory distress and changes in vital

signs occur because of physiological stress
and pain or may indicate development of
shock due to hypoxia or hemorrhage.

Long term goal:

Respiratory rate and rhythm changes are

early warning signs of impending
respiratory difficulties.

Assess fremitus.

Voice and tactile fremitus (vibration) is

reduced in fluid-filled or consolidated
tissue.

Note muscles used for breathing.

The accessory muscles of inspiration are not

usually involved in normal breathing.

Maintain position of comfort,

usually with head of bed elevated.
Encourage client to sit up as much
as possible.

Promotes maximal inspiration; enhances

lung expansion and ventilation in
unaffected side.

Assess changes in orientation,

behavior, anxiety and air hunger.

Restlessness is an early signs of hypoxia.

Instruct patient to do deep

breathing.

Slow, deep breathing aids in effective

breathing pattern and gas exchange, thus,
reducing consumption of energy in patients
with labored breathing.

Provide relaxing environment

To promote adequate rest periods and to

limit fatigue.

Goal met. O2 sat= 98%

RR= 30-34 breaths per
minute.
Able to ambulate around
the room without signs
intolerance and distress.

Collaborative nursing intervention:

Ensure that O2 delivery system is
applied to the patient as ordered.
(Continuous O2 via face mask at
1LPM.)
Administer prescribed medications
as ordered.

So that the appropriate amount of oxygen

is continuously delivered and the patient
does not desaturate.

To aid for faster recovery of patients

condition.

16

Assessment

Objective cues:

-minimal intermittent nose bleeding (12-29-14)

(12-31-14)
-evidence of plasma leakage (pleural effusion)

Chest X ray result:

Pneumonia vs atelectasis, Right lower lobe
Bilateral pleural effusion, more on the right
interfissural fluid minor

Diagnosis

Planning

Risk for bleeding as

evidenced by delayed
promthrobin time, partial
thromboplastin time,
decreased Platelet
Count.

To be able to display
homeostasis as evidenced by
absence of bleeding;
demonstrate appropriate
behaviors and method to
reduce risk of bleeding by
rendering effective health
teachings and reduce the
progression of bleeding for the
whole course of
hospitalization.

Interventions

Rationale

Independent nursing management:

Assess and monitor vital signs

Assess for any signs of G.I bleeding observe

color and consistency
Maintain a safe environmentkeep all
necessary objects and call bell within clients
reach and keep bed in low position. Maintain
bedrest or chair rest when platelets are low,
or as individually appropriate. Assess
medication regimen.

Evaluation

Short term goal:

Increase heart rate and orthostatic
changes accompany bleeding.
The G.I tract is the most usual source of
bleeding
Reduces accidental injury, which could
result in bleeding

Goal met patient

demonstrate appropriate
behaviors and method
that reduce the risk of
bleeding
Long term goal:
Goal met after rendering
effective nursing care no
signs of bleeding noted
with vital signs of BP: 120
over 90 PR of 61 RR: 21
and Temp of 37.2

Hematest body fluidsurine, stool, and

vomitusfor occult blood. Review laboratory
studies, such as Prothrombin time (PT),
activated partial thromboplastin time (aPTT),
clotting time, and Hgb and Hct.

Detects alterations in clotting capability;

identifies therapy needs. Prompt
detection of bleeding and initiation of
therapy may prevent critical loss of blood.

Encourage increase oral fluid intake

For fluid replacement.

Observe for and report epistaxis, hemoptysis,

hematuria, nonmenstrual vaginal bleeding,
or oozing from lesions, body orifices, or IV
insertion sites.

Spontaneous bleeding may indicate

development of disseminated
intravascular coagulation (DIC) or immune
thrombocytopenia, necessitating further
evaluation and prompt intervention.

Monitor for changes in vital signs and skin

color, such as BP, pulse, respirations, and
skin pallor or discoloration.

Presence of bleeding or hemorrhage may

lead to circulatory failure and shock.

Evaluate change in level of consciousness.

May reflect cerebral bleeding.

Collaborative nursing management:

Administer blood products, as indicated.

Transfusions may be required in the event

of persistent or massive spontaneous
bleeding.

Avoid use of aspirin products and NSAIDs,

especially in presence of gastric lesions.

These medications reduce platelet

aggregation, prolonging the coagulation
process, and may cause further gastric
irritation, increasing risk of bleeding. Note:
Aspirin is contraindicated even in the short
term because of its nonreversible effect
on platelets.

Administer IV fluids as prescribed.

For fluid replacement and hydration.

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