I.

INTRODUCTION
Our client Mr. JM 8 years old, living in Norzagaray, Bulacan, was diagnosed with DHF II (Dengue Hemorrhagic Fever stage 2). His primary
complaints are abdominal pain, headache and fever. He is a grade three student and studying at FVR elementary school. His parents are Mrs. A 33 years
old and Mr. M 42 years old. Our patient was born in Korean because his parents are working on that country.
Dengue Fever is caused by one of the four closely related, but antigenically distinct, virus serotypes Dengue type 1, Dengue type 2, Dengue type 3,
and Dengue type 4 of the genus Flavivirus and Chikungunya virus. Infection with one of this serotype provides immunity to only that serotype of life, to a
person living in a Dengue-endemic area can have more than one Dengue infection during their lifetime. Dengue fever through the four different Dengue
serotypes are maintained in the cycle which involves humans and Aedes aegypti or Aedes albopictus mosquito through the transmission of the viruses to
humans by the bite of an infected mosquito. The mosquito becomes infected with the Dengue virus when it bites a person who has Dengue and after a week
it can transmit the virus while biting a healthy person. Dengue cannot be transmitted or directly spread from person to person. Aedes aegypti is the most
common aedes specie which is a domestic, day-biting mosquito that prefers to feed on humans.
.The biggest increase of Dengue cases in the country was seen in Metro Manila, where there was an almost 200 percent increase. According to
government figures 15,061 cases of the disease in the Philippines were reported in the first six months of the year. 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. Deaths due to dengue rose to 172
compared with 115 for the first half of 2007. Metro Manila had the highest number of cases, an increase of 191 percent over the same period in 2007.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. The Philippines Department of Health
(DOH) today reported that a total of 2,332 dengue cases has been admitted to sentinel hospitals nationwide from January 1 to May 15 this year. There were
sixteen deaths recorded. Partial reports from the DOH National Epidemiology Center (NEC) indicate a 58% decrease in the number of cases this year
compared with the same period last year. The NEC report also revealed that the regions with the highest number of cases were the National Capital region

(732 cases), Region 3 (307), Region 5 (268), and Region 7 (231). The ages of cases ranged from 1 month to 75 years old, with forty-six percent (535) of the
cases belonging to the 1-9 years age group.

OBJECTIVES:

Knowledge Objectives:
-

To acquire knowledge about DHF.

To know the effects of DHF to our patient and the right intervention specified for him.

To know the essentiality of the case that would assist us student-nurses to build a holistic knowledge, skills and attitude approach to learning .

Skill Objective:
1. Identify the risk factors that occur in the disease and make a pathophysiology about the disease.
2. Formulate significant diagnosis that is related to Nursing Care Plan and make a nursing care plan.
3. Identify the medications administered to the client and the drugs indication, contraindication, side effects, and nurses responsibility.

Attitude Objective:
1. To build trust and rapport to the patient.
2. To gain cooperation and trust from the patient.
3. To gain trust and cooperation from the relatives of the patient.

II.

NURSING ASSESSMENT

A. PERSONAL DATA
NAME: Mr. JM
AGE: 8 years old
SEX: Male
ADDRESS: Friendship Village Resour, Norzagaray Bulacan
MARITAL STATUS: Single
BIRTHDATE: February 16, 2002
NATIONALITY: Filipino
BIRTHPLACE: Korea
EDUCATIONAL ATTAINMENT: Grade 3 student
POSITION IN THE FAMILY: Son
RELIGION: Roman Catholic
HEALTH CARE FINANACING AND USUAL SOURCES OF MEDICAL CARE: Mother
DATE ADMISSION: September 6, 2010
TIME: 1:20 pm
B. CHIEF COMPLAINT
Mr. JM was admitted to Bulacan Medical Center with a chief complaint of abdominal pain and headache.
C. HISTORY OF THE PRESENT ILLNESS
The client experienced having abdominal pain every time his stomach is full. He was just lying on bed when the abdominal pain started. He was
brought by his mother to Roquero hospital because of having fever, abdominal pain and headache and after 2 days he was transferred to BMC because his
family observes having no improvement on their sons situation. He was given Ampicillin and Augmentin at the Roquero hospital. He was given Ranitidine
at the BMC hospital for treatment of the abdominal pain.
D. HISTORY OF THE PAST ILLNESS
The client doesnt have any allergies and havent encountered any accident or injuries. He has completed his immunization according to his aunt. It
was his second hospitalization because he was just transferred to BMC. He just had taken Paracetamol every time he experience having fever and headache.
3

E. FAMILY HEALTH ILLNESS HISTORY

GENOGRAM
EM
73 Y/O

HM
84 Y/O
HPN

OM
47 Y/O

KM
44 Y/O

MM
42 Y/O

YC
89 Y/O

KC
76 Y/O

AM
33 Y/O

AC
30 Y/O

MALE
FEMALE
PATIENT

DECEASED

ASTHMA

HPN Hypertension
JM
8 Y/O

Arthritis

The client is the only child of Mr. M.M and Mrs. A.M. He was born in Korea where his parents are working; when he was around 26 days old thats
the time he was brought here in the Philippines. It was the first incidence of having Dengue in their family. His grandfather has arthritis and hypertension
while his grandmother has asthma and the rest of the families are healthy.

F. FUNCTIONAL HEALTH PATTERN

A. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN
The clients health has been better. Prior to hospitalization he has no colds but if it happens their first aid is to drink herbal medicines and if it doesnt
work they will seek for a doctors consultation. They think that the illness is caused by the poor sanitation of the place where they stayed at Tondo, Manila
and when they went to Norzagaray, Bulacan thats when the symptoms started. He was rushed to the hospital after experiencing abdominal pain, headache
and high fever.
B. NUTRITIONAL AND METABOLIC PATTERN
The client loves to eat fried chicken and he always eats fruits every breakfast and drinks milk twice a day. He also has a good appetite prior to
hospitalization, while during hospitalization he has poor appetite because of the feeling of weakness and he doesnt like the food. During his hospitalization,
he is restricted by his doctor to eat dark colored foods. He doesnt have any skin problems or any dental problems.
C. ELIMINATION PATTERN
The client urinates 4x a day during his hospitalization with a yellowish color about 100 ml per voiding. He defecate once a day everyday with a
formed color brown stool.
URINE
STOOL

AMOUNT
100 ml

FREQUENCY
4 times a day
Once a day

COLOR
Yellow
Brown

ODOR
Pungent
Foul

D. ACTIVITY-EXERCISE PATTERN
Mr. JM has sufficient energy for completing his desired activities, like during playing and doing activities at school. During his spare time he would
play outdoor activities with his neighbors.
0-Feeding
0-Dressing
IV- Home maintenance

0-Bathing
0-Grooming
II-Shopping

0-Toileting
0-General Mobility

0-Bed Mobility
IV-Cooking

Level 0- full self care

Level I- requires use of equipment or device
Level II- requires assistance or supervision from another person
Level III- requires assistance or supervision from another person or device
Level IV- is dependent and does not participate
E. SLEEP-REST PATTERN
The client has a regular sleeping pattern because of having 10 hrs. of sleep starting from 8pm-5am. He has a continuous sleep and often takes nap in
the afternoon after school. He doesnt have any problem falling asleep.
F. COGNITIVE PERCEPTUAL PATTERN
The client has no difficulty in hearing and on vision. He learned through school and family. Prior to hospitalization, he experienced abdominal pain
and headache and he took Paracetamol to lessen the pain that he is experiencing,
G. SELF-PERCEPTION AND SELF-CONCEPT PATTERN
He felt good about himself. Since the illness started he missed some of his classes in school. He felt angry every time he wouldnt get what he wanted
and being tearful every time he was forced to do something he wouldnt like to do.
H. ROLE-RELATIONSHIP PATTERN
He belongs to an extended family. Every time they have a problem they will just communicate with each other to solve the issue. His parents are
really affected with his hospitalization because they are not here to take care of him. His relatives were the one taking good care of him while he in the
hospital.
I. SEXUALITY-REPRODUCTIVE PATTERN
Not applicable
J. COPING STRESS TOLERANCE PATTERN
He had no big problem in his life, sometimes he experience having fight with his playmates but still they where able to solve it by themselves.

K. VALUE-BELIEF PATTERN
The client is a catholic and they believe in God. For their family it is really important to have a connection to God. It really helps every time they are
facing a problem and during his stay in the hospital his family is praying for his wellness.
G. GROWTH AND DEVELOPMENT
PSYCHOSOCIAL

PSYCHOSEXUAL

COGNITIVE

MORAL

STAGE
School Age
Industry vs. Inferiority

DEFINITION

At this stage, the children

begin to create and develop a
sense of competence and
perseverance. They are
motivated by activities that
provide a sense of worth. They
concentrate on mastering skills
that will help the, function in
the adult world. Although
children of this age work hard
to succeed, they are always
faced with the possibility of
failure, which can lead to a
sense of inferiority. If children
have been successful in
previous stages, they are
motivated to be industrious
and to cooperate with others
toward a common goal

Latency (Genital Stage)

The stage begins around the

time that children enter into
school and become more
concerned with peer
relationships, hobbies, and
other interests. The latent
period is a time of exploration
in which the sexual energy is
still present, but it is directed
into other areas such as
intellectual pursuits and social
interactions. This stage is
important in the development
of social and communication
skills and self-confidence.

Concrete Operations Phase

Conventional (Interpersonal
Concordance Orientation
Stage)

Cognitive development refers

to the manner in which people
learn to think, reason, and use
language. It involves a
persons intelligence,
perceptual ability, and ability
to process information. At
concrete operations phase it
solves concrete problems. The
child begins to understand
relationships such as size.
They understand right and left.
The child has cognizant of
viewpoints. In this stage
(characterized by 7 types of
conservation: number, length,
liquid, mass, weight, area,
volume), intelligence is
demonstrated through logical
and systematic manipulation of

At Conventional level, person

is concerned with maintaining
expectations and rules of the
family, group, nation, or
society. A sense of guilt has
developed and affects
behavior. The person values
conformity, loyalty, and active
maintenance of social order
and control. Conformity means
good behavior or what pleases
or helps another and is
approved Societal focus. In
interpersonal concordance
orientation he decisions and
behavior are based on concerns
about others reaction; the
person wants others approval
or a reward.

symbols related to concrete

objects. Operational thinking
develops (mental actions that
are reversible). Egocentric
thought diminishes.
ANALYSIS

Our client has reached this

stage. He is a grade 3 student;
through social interactions to
his classmates and friends he
developed a sense of pride in
his accomplishments and
abilities. According to our
patient, he is always
encouraged and commended
by his parents and teachers
when he did something good.
By encouraging and
commending a child, our client
developed a feeling of
competence and belief in his
skills. He also stated, that his
parents always letting him to
do what he wants to do but
within the scope of his age.

Mr. JM developed a strong

sexual interest in his opposite
sex like his friends. According
to him, during his earlier age
(around 5 to 7 years old) he
was solely focus on his
individual needs and interests
in the welfare of others. He
also stated that he is always
socialized to his friends and
classmates during their spare
time in school.

Our client thinks logically

about concrete events, but has
difficulty understanding
abstracts or hypothetical
concepts. He also understands
the awareness that actions can
be reversed because he is able
to reverse the order of
relationships between
categories.

Our client stated that his

parents always calling him as a
good-boy because according
to him he is always following
the saying and rules of his
parents.

III.

ANATOMY AND PHYSIOLOGY

Circulatory System

THE SYSTEMIC CIRCULATION

Major arteries (in bright red) and veins (dark red) of the system
Blood from the aorta passes into a branching system of arteries that lead to all parts of the body. It then flows into a system of capillaries where its exchange
functions take place.
Function only: to supply materials to and remove materials from the capillaries. Blood from the capillaries flows into venules which are drained by
veins.

Veins draining the upper portion of the body lead to the superior vena cava.

Veins draining the lower part of the body lead to the inferior vena cava.

Both empty into the right atrium.

BLOOD
Blood is a liquid tissue. Suspended in the watery plasma are seven types of cells and cell fragments.

red blood cells (RBCs) or erythrocytes

platelets or thrombocytes

kinds of white blood cells (WBCs) or leukocytes

Three kinds of granulocytes

10

neutrophils

eosinophils

basophils

Two kinds of leukocytes without granules in their cytoplasm

lymphocytes

monocytes

FUNCTIONS OF THE BLOOD

Blood performs two major functions:

transport through the body of

oxygen and carbon dioxide

food molecules (glucose, lipids, amino acids)

ions (e.g., Na+, Ca2+, HCO3)

wastes (e.g., urea)

hormones

heat

11

Defense of the body against infections and other foreign materials. All the WBCs participate in these defenses

All the various types of blood cells

Are produced in the bone marrow (some 1011 of them each day in an adult human!).

Arise from a single type of cell called a multipotent stem cell.

These stem cells

are very rare (only about one in 10,000 bone marrow cells);

are attached (probably by adherens junctions) to osteoblasts lining the inner surface of bone cavities;

produce, by mitosis, two kinds of progeny:

More stem cells (A mouse that has had all its blood stem cells killed by a lethal dose of radiation can be saved by the injection of a single

living stem cell!).

Cells that begin to differentiate along the paths leading to the various kinds of blood cells.

12

IV.

THE PATIENT AND HIS ILLNESS

A. PATHOPHYSIOLOGY (Schematic Diagram)

Non Modifiable
Factors;
-age

Modifiable Factors;
-environment
(sanitation)

Bite of aedes mosquito

Dengue flavi virus mix
in the blood circulation
Immune system recognizes the
viral invasion; triggers immune
response

WBC
13

Macrophages will release pyrogens that

would stimulate the thalamus to body
temp.

Megakaryocytes desentigrate as core body temp.

continue to rise which would result to platelet
count.

Platelet count would now decrease

the clothing capability hemorrhage

Hemorrhage in the micro circulation of

the gums (that could cause bleeding
gums)

14

PHYSICAL ASSESSMENT
Name: Mr. JM
Birthday: February 16, 2002
Age: 8 y/o
Date of Assessment: Sept. 08, 2010
Weight: 27 kg.
Height: 411
Parts to be Examined
1. GENERAL SURVEY
Body built, height & weight in
relation to clients age, lifestyle
and health

Vital signs:
Temperature: 38.4C
Pulse rate: 90 bpm
Respiratory rate: 35 cpm
Blood pressure: 100/70mmHg
BMI: 12.0
Technique

Normal Findings

Actual Findings

Inspection

Proportionate, varies
with lifestyle

He has a proportionate
body built which is
appropriate with his
lifestyle
He is slightly
unrelaxed and has
minimal movements

Clients posture and gait, standing,

sitting and walking

Inspection

Relaxed, erect
posture; coordinated
movement

Clients overall hygiene and

grooming

Inspection

Clean, neat

Inspection
Body and breath odor

No body odor or
minor body odor
relative to work or

He dresses cleanly,
neatly and
appropriately.
He has no body &
breath odor.

Interpretation
Normal
Deviation from
Normal due to
discomfort and
illness.
Normal
Normal

15

Clinical Measurements
Height
Weight

exercise; no breath
odor
Underweight = <18.5
Inspection
Normal weight = 18.524.9

Inches 411
27 kg.
BMI =12.0

The client is
underweight
based on the
result of BMI.

Overweight = 25-29.9
Obesity = BMI of 30 or
greater
Vital Signs
Temperature
Pulse rate
Respiratory Rate
Blood Pressure

Inspection
Palpation
Inspection
Auscultation and
Palpation

36.5-37.5 C
60-100bpm
12-21cpm
120/80mmhg

38.4 C
90bpm
35cpm
100/70mmhg

BEHAVIOR
Signs of distress, in posture or
facial expression

Inspection

No distress noted

On stress

Signs of health or illness

Inspection

Healthy appearance

Inspection

Cooperative, able to
follow instructions

Inspection

Appropriate to
situation

He has an unhealthy
appearance
He is very cooperative
and able to follow my
instructions
He responds
appropriately

Clients attitude
Clients affect/mood;
appropriateness of clients
response
Quantity of speech, quality

Understandable,

Temperature are
elevated due to
increased WBC

Deviation from
Normal due to
hospitalization.
Deviation from
Normal due to
illness.
Normal
Normal

He speech is slightly

16

Inspection

Relevance and organization of

thoughts
2. INTEGUMENTARY
A. SKIN
Color and uniformity of color

Inspection

Inspection

Presence of edema

Inspection

Presence of lesion according to

location, distribution, color,
configuration, size, shape, type or
structure

Inspection

Skin moisture

Inspection

moderate pace; clear

tone and inflection;
exhibit thought
association
Logical sequence;
makes sense; has
sense of reality

Varies from light to

deep brown; ruddy
pink to light pink;
from yellow
overtones to olive
Generally uniform
except in areas
exposed to the sun;
areas of lighter
pigmentation in darkskinned people
No edema
Freckles, some
birthmarks, some flat
and raised nevi; no
abrasions or other
lesions
Moisture in skin folds
and axillae (varies
with environmental
temperature and

understandable,clear
and has association of
thoughts
He has relevance of
thoughts that makes
sense and has a sense
of reality

Pale in color, Herman

signs are present

He has edema on the

IV site
He has no lesion; no
abrasions or other
lesions

He has warm and silky

skin moisture.

Normal

Normal

Deviation from
Normal d/t
decreased tissue
perfusion &
peripheral
vasoconstriction.

Deviation from
normal d/t IV
infusion
Normal
Deviation from
Normal d/t
uncomfortable
environment.

17

humidity and activity)

Uniform; within
normal range

Skin temperature

Palpation

Skin turgor

Palpation

Skin springs back to

previous state; has a
good skin turgor

B. NAILS
Fingernails shape, curvature and
angle

Inspection

Fingernail and toenail texture

Palpation

Fingernail and toenail bed color

Inspection

Convex curvature;
angle of nail plate
about 160
No visible lines and
cracks Smooth texture
Highly vascular and
pink in light-skinned
people; dark-skinned
may have brown or
black pigmentation in
longitudinal streaks

Tissues surrounding nails

Inspection
Intact epidermis

Blanch test of capillary refill

3. HEAD
A. SKULL
Size, shape and symmetry

Palpation

Prompt return of pink

or usual color;
Delayed 1-2 sec

Inspection

Rounded
(normocephalic);
smooth skull contour

His skin temperature

is warm
With redness when
pinched
His nail has a convex
curvature
approximately 160
He has a smooth nails
without any damages
Pallor

He has an intact
epidermis with no
hangnails
There is a prompt
return of blood
resulting to the usual
color, delayed for 4
sec.
His skull is rounded
and has a smooth skull
contour

Deviation from
normal due to
increase body
temperature
Deviation from
Normal d/t blood
circulation
Normal
Normal
Deviation from
Normal d/t poor
arterial
circulation.

Normal
Deviation from
Normal d/t poor
arterial
circulation.

Normal

18

Presence of nodules, masses and

depressions
B. SCALP
Color and appearance
Areas of tenderness
C. HAIR
Evenness of growth, thickness and
thinness
Texture, oiliness over the scalp
Color
D. FACE
Facial features, symmetry of facial
movements
4. EYES
Inspect the eyes for edemas and
hallowness
A. EYEBROWS
Evenness of distribution and
direction of curl

B. EYELASHES
Evenness of distribution and

Palpation

Smooth, uniform
consistency; absence
of nodules and masses

He has no nodules and

masses

Inspection

Usually white but it

also depends on darkskinned people
No tenderness

His scalp is white and

has a smooth surface
There are no areas of
tenderness

Normal

Evenly distributed
thick hair
Smooth texture; no
oiliness

He has a thick hair and

it is evenly distributed
He has a smooth scalp
and oily and brittle
hair.
Black with short hair.

Normal
Deviation from
normal due to
hospitalization.
Normal

He has asymmetrical
facial features which
has asymmetrical
movements

Deviation from
Normal d/t illness
and
hospitalization.

No edema

Normal

Palpation
Inspection
Palpation
Inspection

Black

Inspection

Symmetrical facial
features and
movements

Inspection

No edema

Normal

Normal

Inspection

Hair evenly
distributed and the
curl is outward

He has an evenly
distributed hair in her
eyebrow and they are
aligned with equal
movement

Normal

Inspection

Equally distributed;

His eyelashes are

Normal
19

direction of curl
C. EYELIDS
Surface characteristics, position in
relation to the cornea, ability to
blink and frequency of blinking

D. CONJUNCTIVA
Bulbar Conjunctiva for color,
texture and presence of lesions

Palpebral Conjunctiva for color,

texture and presence of lesions
E. SCLERA
Color and clarity
F. CORNEA
Clarity and texture

G. IRIS
Shape and color

curls slightly outward

equally distributed and

curled outward

Inspection

Skin intact; no
discharge or
discoloration; Lids
closed symmetrically
approximately 15-20
involuntary blinks per
minute

He has a smooth
eyelids with no
discharge; lids closed
symmetrically and has
15-20 blinks per
minute

Normal

Inspection

Transparent
capillaries sometimes
evident

Normal

Inspection

Shiny, smooth and

pink or red

His Bulbar
Conjunctiva is
transparent and has
some visible small
capillaries
He has shiny, smooth
and reddish palpebral
conjunctiva

Deviation from
Normal d/t blood
circulation.

Inspection

Sclera appears white

He has white sclera

Normal

Inspection

Transparent, shiny
and smooth; the
details of iris are
visible

He has a transparent,
shiny and smooth
cornea

Normal

Inspection

Rounded shape which

are the same in each
eye; color varies
depending on the race
and the color is
evenly distributed

He has a dark brown

iris which is uniform
and they are both
rounded

Normal

20

H. PUPILS
Color, shape and symmetry of size

Inspection

Black in color, equal

in size and smooth
border

His pupils are black,

equal in size and has
smooth borders

Normal

I. VISUAL ACUITY
Near Vision

Inspection

Able to read
newsprints

Normal

Distant Vision

Inspection

When looking straight

ahead, client can see
objects in the
periphery

He has been able to

read newsprints with
the use of eye glasses
N/A
(no equipment)

Inspection

Illuminated pupils
constricts
Pupils also constricts
when looking at near
objects, dilate when
looking at far objects
and converge when
near object is moved
toward the nose

N/A

J. PUPILS
Light reaction and accommodation

5. LACRIMAL GLAND / SAC &

NASOLACRIMAL DUCT
Lacrimal Gland
A. EXTRAOCULAR MUSCLES
Alignment and coordination

His pupils constrict

when light passes and
it also converge when
near object is moved
toward his nose

Normal

Inspection and
palpation

No edema, tenderness
or tearing

There are no edema,

tenderness and tearing
noted from the client

Normal

Inspection

Both eyes
coordinated, move in
unison, with parallel
alignment

His both eyes are

coordinated, move in
unison with parallel
alignment

Normal

B. VISUAL FIELD
21

Peripheral visual fields

6. EARS
A. AURICLES
Color, symmetry of size and
position

Texture, elasticity and areas of

tenderness
B. EXTERNAL EAR CANAL
Cerumen, skin lesions, pus and
blood

C. HEARING ACUITY TESTS

Clients response to normal voice
tone
Watch tick test

Inspection

When looking straight

ahead, client can see
objects in the
periphery

He can see objects in

the periphery

Normal

Inspection

Color same as facial

skin; symmetrical;
auricle aligned with
outer canthus of eye
about 10 vertical

Normal

Palpation

Mobile, firm and not

tender; pinna recoils
after being folded

His ears skin color is

same as the
surrounding skin and
both are symmetrical;
the auricles are
aligned in the outer
canthus of each eye
His auricles are
mobile, firm and not
tender; his pinna
recoils when folded

Inspection

Dry cerumen,
grayish-tan color,
sticky or wet cerumen
in various shades of
brown

He had no visible
cerumen, has a grayish
color

Normal

Inspection

Normal voice tones

audible
Able to hear ticking
sound in both ears
Sound is heard at both
ears or at the center
(Webers negative)
Air conduction is
greater than the bone

Inspection

Webers test

Inspection

Rinne test

Inspection

His voice tones is audible

Normal

Normal

He can hear ticking sound in

both ears
He heard at both ears or at the
center (Webers negative)

Normal

Air conduction is greater than

the bone conduction (Rinne

Normal

Normal

22

conduction (Rinne
Positive)
7. NOSE
Deviations in shape, size or color
and flaring or discharge
Nasal cavities for presence of
redness, swelling, growths and
discharge
Nasal septum between the nasal
chambers
Patency of both nasal cavities

Inspection

Tenderness, masses and

displacement of bones and
cartilage

Palpation

Symmetric and
straight; no discharge
or flaring; uniform
color
Mucosa pink; clear
watery discharge; no
lesions
Nasal septum intact
and in midline
Air moves freely as
the client breathes
through the nares
Not tender

Palpation

Not tender

His sinuses are not

tender

Normal

Inspection

Uniform pink color,

soft, moist, smooth
texture, symmetry of
contour, ability to
purse lips

He has a pale in color

lips, slightly dry and
smooth; it has
symmetry of contour
and has the ability to
purse his lips

Deviation from
Normal d/t
illness.

Inspection

Moist, smooth, soft,

glistening and elastic

He has a moist, soft,

glistening and elastic

Normal

SINUSES
Tenderness
8. MOUTH
A. LIPS
Symmetry of contour, color and
texture

B. BUCCAL MUCOSA
Color, moisture, texture and
presence of lesions

Inspection

Positive)

Inspection
Inspection

His nose are uniform in color

same as with the surrounding
skin; there are no discharge
and flaring
He has a clear watery
discharge and has no apparent
lesions
His nasal septum is in the
middle
He usually breathes freely
through his nares

Normal

There are no
tenderness, masses or
displacement of bones
and cartilage

Normal

Normal
Normal
Normal

23

C. TEETH
Color, number, condition and
presence of dentures
D. GUMS
Color and condition
E. TONGUE/ FLOOR OF MOUTH
Color and texture of the mouth and
frenulum

texture

texture of his buccal

mucosa

Pre-schooler teeth;
smooth, white and
shiny tooth enamel

He has a shiny tooth

enamel without any
dental problems

Inspection

Pink gums; moist and

firm texture to gums;
no retractions

His gums are pinkish

to reddish in color

Inspection

Central position; Pink

color, moist, slightly
rough; thin whitish
coating, lateral
margins; no lesions;
raised papillae
Moves freely; no
tenderness; smooth
tongue base with
prominent veins
Smooth with no
palpable nodules

His tongue is in the

center, pink in color, it
is moist, slightly rough
without lesions; it has
a thin whitish coating
and lateral margins
His tongue moves
freely with weak
tenderness
It has no nodules

Normal

Light pink, smooth,

soft palate
Lighter pink hard
palate, more irregular
Positioned in midline
of soft palate

He has pale in color

and smooth soft palate
while pale and
irregular hard palate
The uvula is in the
middle

Deviation from
Normal d/t
decrease blood
circulation
Normal

Pink and smooth

posterior walls

He has a smooth and

pinker posterior walls

Normal

Inspection

Position, color and texture,

movement and base of tongue

Inspection and
palpation

Presence of nodules, lumps or

excoriated areas
F. PALATES AND UVULA
Color, shape, texture, and presence
of bony preminences

Palpation

Position of uvula and mobility

while examining the palates.
G. OROPHARYNX AND TONSILS
Color and texture

Inspection

Inspection
Inspection

Normal
Deviation from
normal due to
bleeding

Normal

Normal

24

Size of tonsils, color and discharge

Inspection

Pink and smooth; no

discharge; of normal
size

Presence of Gag reflex

Inspection

Gag reflex is present

Inspection and
palpation

9. NECK
A. LYMPH NODES
Lymph Nodes and tenderness
B. TRACHEA
Placement

C. THYROID GLAND
Symmetry and visible masses
Smoothness, enlargement and
nodules
10. THORAX
A. POSTERIOR
Shape, symmetry, compare the
diameter of anteroposterior to
transverse diameter

His tonsils are pink

and smooth without
discharge and of
normal size
He has a positive
gag/cough reflex

Normal

Not palpable

His nodes are not

palpable

Normal

Inspection and
palpation

Central placement in
midline of neck;
spaces are equal in
both sides

His trachea is in the

middle with equal
spaces on both sides

Normal

Inspection

Not visible on
inspection
Glands ascends
during swallowing;
painless, centrally
located and smooth

It is not visible

Normal

His thyroid glands rise

when swallowing; it is
smooth and painless

Normal

His chest are

symmetric;
anteroposterior to
transverse has a
diameter ratio of 1:2
His spine is vertically
aligned
His skin is intact and
has uniform warm

Normal

Palpation

Inspection

Chest symmetric;
anteroposterior to
transverse diameter in
ratio of 1:2

Spinal alignment

Inspection

Temperature, tenderness and

masses

Palpation

Spine vertically
aligned
Skin intact; uniform
temperature

Normal

Normal
Normal

25

Respiratory excursion

Inspection and
palpation

Vocal fremitus

Palpation

Percuss the thorax

Percussion

Auscultate the thorax

B. ANTERIOR
Breathing patterns
Temperature, tenderness and
masses
Respiratory excursion

Vocal fremitus

Auscultation

Full and symmetric

expansion; as the
client breathes,
thumbs usually
separates 3-5cm
Bilateral symmetry of
vocal fremitus; it is
heard mostly at the
apex of lungs
Percussion notes
resonance except over
scapula
Lowest point of
resonance is at the
diaphragm
Vesicular and
bronchovesicular
sounds

Inspection

Quiet, rhythmic and

effortless respiration

Palpation

Skin intact; uniform

temperature

Inspection and
palpation

Full and symmetric

expansion; as the
client breathes,
thumbs usually
separates 3-5cm
Bilateral symmetry of
vocal fremitus; it is

Palpation

temperature
He has a full and
symmetric expansion
and as she breathes,
thumbs usually
separate for 3-5 cm.
He has a bilateral
symmetry of vocal
fremitus; it is heard
clearly at the apex
His percussion notes
resonance sound
except over the
scapula and the lowest
resonance heard is at
the diaphragm
There are vesicular
and bronchovesicular
sounds heard
He has a quiet,
rhythmic and
effortless respiration
His skin is intact and
has uniform warm
temperature
He has a full and
symmetric expansion
and as he breathes,
thumbs usually
separate for 3-5 cm.
He has a bilateral
symmetry of vocal

Normal

Normal

Normal

Normal

Normal
Normal
Normal

Normal

26

Percuss the anterios thorax

Percussion

Auscultate the trachea

Auscultation

Auscultate the thorax

Auscultation

11. CARDIOVASCULAR
Aortic and pulmonic areas
Tricuspid area
Apical area

Epigastric area
Auscultate aortic, pulmonic, apical,
tricuspid and epigastric area

12. CAROTID ARTERIES

Palpate with extreme caution

Inspection and
palpation
Inspection and
palpation
Inspection and
palpation
Inspection and
palpation
Auscultation

Palpation

heard mostly at the

apex of lungs
Percussion notes
resonance except over
ribs
Lowest point of
resonance is at the
diaphragm
Bronchial or tubular
breath sounds
Vesicular and
bronchovesicular
sounds

fremitus; it is heard
clearly at the apex
His percussion notes
resonance sound
except over the ribs
and the lowest
resonance heard is at
the diaphragm
There are bronchial or
tubular sounds heard
There are vesicular
and bronchovesicular
sounds heard

No pulsation

No pulsations felt

Normal

No pulsation; no lift
or heave
Some pulsations
visible; no lift or
heave

No pulsations or lift
and heave
There are some
pulsations felt but
there are no lift or
heave
There are aortic
pulsations
There are heart sounds
heard in all sites

Normal

His carotid artery has

a full symmetric pulse

Normal

Aortic pulsations
S1-usually heard at all
sites but louder at the
apical area
S2-usually heard at all
sites but louder at the
base of heart
Symmetric pulse
volumes; full

Normal

Normal
Normal

Normal

Normal
Normal

27

pulsations
Auscultate the carotid arteries

volumes and
pulsations
There are no sounds
heard

Auscultation

No sounds heard

13. JUGULAR VEINS

Presence of veins

Inspection

Veins not visible

There are no visible

veins

Normal

14. ABDOMEN
Skin integrity

Inspection

Unblemished skin,
uniform color
Flat, rounded or
scaphoid
No evidence of
enlarged liver and
spleen
Symmetric contour

He has unblemished
skin, uniform color
He has symmetric
contour
There are no evidence
of enlarged liver and
spleen
He has a symmetric
contour
He has symmetric
movements because of
respiration
There are no vascular
patterns seen
There are audible
bowel sounds heard
every 30 seconds but
no arterial bruits and
friction rub
There is tymphany
over stomach and gas
filled bowels

Normal

Abdominal contour

Inspection

Enlarged liver or spleen

Inspection

Symmetry of contour

Inspection

Abdominal movements

Inspection

Vascular patterns

Inspection

Bowel sounds, vascular sounds and

peritoneal friction rubs

Auscultation

Percuss in each quadrants

Percussion

Light palpation of quadrants

Palpation

Symmetric
movements caused by
respiration
No visible vascular
patterns
Audible bowel sounds
usually occur every 520seconds; absence of
arterial bruits and
friction rub
Tympany over
stomach and gasfilled bowels; dullness
over the liver and
spleen or full bladder
No tenderness,

There is no tenderness,

Normal

Normal
Normal
Normal
Normal
Normal
Normal

Normal

Normal
28

relaxed abdomen with

smooth, consistent
tension

his abdomen is relaxed

with smooth consistent
tension

Inspection

Equal size on both

sides of the body

Inspection
Inspection
Palpation
Inspection and
Palpation

No contractures
No tremors
Normally firm
Smooth coordinated
movements

He has equal muscle

size on both sides of
the body
He has no contractures
He has no tremors
He has firm muscles
He has a weak and
slight un-coordinated
movements

B. BONES
Normal structure and deformities
Edema and tenderness

Inspection
Palpation

No deformities
No tenderness or
swelling

He has no deformities
He has no edema,
tenderness and
swelling

Normal
Normal

C. JOINTS
Swelling

Inspection

No swelling

Positive swelling

Deviation from
Normal d/t
uncomfortable
environment.

Palpation

No swelling,
tenderness, crepitation
or nodules

There are no
tenderness, swelling,
crepitation or nodules;

Normal

15. MUSCULOSKELETAL
A. MUSCLES
Size, comparison on one side to
other side
Contractures
Fasciculation and tremors
Muscle tonicity
Muscle strength

Tenderness, smoothness of
movements, crepitation and
nodules

Normal
Normal
Normal
Normal
Deviation from
Normal d/t
illness.

29

Joint range of motion

Inspection

Varies to some degree

in accordinance with
persons genetic
makeup and degree of
physical ability.

He has a good joint

ROM.

Normal

DIAGNOSTIC PROCEDURE/ LABORATORY

Diagnostic
Laboratory
Procedure
Complete
Blood
Count

Date
Ordered

`Indication or Purpose

Sept.
07, 2010

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

Result

Components
WBC
RBC
HGB
HCT
PLT
PCT
MCV
MCH
MCHC
RDW
MPJ
PDW
%Lymphocytes
#Lymphocytes
%Monocytes
#Monocytes

Actual Findings
2.2 L 109/L
6.20 H 1012/L
100 g/L
0.330
69 L 109/L
0.046 L 10-2/L
72 L fl
25.5 L pg
356 H g/L
16.7 H%
6.6 fl
10.1 %
39.3 %
0.8 L 109 L
13.3 H%
0.2 L 109L

Normal Values

Normal Findings
3.5 10.0
3.80 5.80
110 165
0.350 0.500
150 390
0.100 0.500
80 97
26.5 33.5
315 350
10.0 15.0
6.5 11.0
10.0 18.0
17.0-48
1.2-3.2
4.0-10.0
0.3-0.8

Analysis and Interpretation

of Result
Analysis/Interpretation
Abnormal/Decreased
Abnormal/Elevated
Normal
Normal
Abnormal/Decreased
Abnormal/Decreased
Abnormal/Decreased
Normal
Abnormal/Elevated
Abnormal/Elevated
Normal
Normal
Normal
Abnormal/Decreased
Abnormal/Elevated
Abnormal/Decreased

Nursing
Responsibilities
Before:
-Identify the
patient
-explain the
procedure to the
patient
-Inform the
patient that there
are no foods,
fluids, or
medications
restrictions,
unless by
medical
directions.
During:
-Instruct the
patient to
30

as leukemia
to monitor treatment for
anemia and other blood
diseases
To determine the effects
of chemotherapy and
radiation therapy on
blood cell production.

V.

%Granulocytes
#Granulocytes

47.4 %
1.2 L 109L

43.0-76.0
1.2-6.8

cooperate fully
and to follow
directions
during the
laboratory
procedures.
After:
-Secure the
laboratory
results of the
patient.

Normal
Normal

THE PATIENT AND HIS CARE

A. MEDICAL MANAGEMENT
a. IVF, BLOOD TRANSFUSION, NEBULIZATION, TOTAL PARENTERAL NUTRITION, NGT, OXYGEN THERAPY ETC.

MEDICAL
MANAGEMENT

D5 0.3 NaCl
500 cc @
25 gtts/ min

DATE
ORDERED,
DATE RESULT
IN

GENERAL
DESCRIPTION

September 6, 2010 Hypertonic

Crystalloid
Sterile, nonpyrogenic and
contain no
bacteriostatic or
antimicrobial
agents. It contains

INDICATION/
PURPOSES

CLIENTS
RESPONSE

Hypertonic solution draws

fluids from the ICF causing
cells to shrink and ECF to
expand.
Given to patients with
hyponatremias (Na deficits)
with edema.
IVF may also come in a form

The patient gets

sufficient energy for the
body and the brain to
function well.

NURSING
RESPONSIBILITIES

-Frequently check the IVF

site for infiltration, dislodge
and inflammation
-Explain the purpose of the
IVF to the patients family.

31

Normal Saline
Solution
250 cc as fast
Drip

September 06,
2010

77 mEq/L solution
and 77 mEq/L
chloride.

of nutrient solution,
electrolyte solution,
alkalyzing solution &
acidifying solution.

Solution of
common salt in
distilled water, of a
strength of 0.9 per
cent. It is called
normal saline
because the
percentage of salt
resembles that of
the crystalloids in
the blood plasma.
Applied to a
wound an isotonic
causes no increase
in the flow of
lymph from the
capillary blood
vessels.

-Can be use to replace fluids

in dehydration, go with blood
transfusion, hyponatremia,
and burn victims. It is
isotonic.
-to dilute medications and to
clean wounds out and to
clean wounds out and other
things.
-fast drip for low BP in
dengue hemorrhagic fever
patient.

The patient gets

sufficient energy for the
body and the brain to
function well.

-monitor for urine output,

which should be 100ml or
more every 4hrs.
-assess IV site carefully to
avoid extravasations and
tissue necrosis.
-monitor renal function,
urinary output, fluid balance
and electrolytes level.

32

b. Drugs
Generic/ Brand
name
Ranitidine
Hydrochloride
(Zantac, Gavilast,
Aporanitidine.Ranitil
Ulzan)

Date ordered, date

taken/Given, date
changed, date
discontinued
September 6, 2010

Route of
administration,
dosage, frequency
250mg TIV q 8

General action,
classification,
mechanism of
action
Histamine-receptor
antagonist
Anti ulcer drug
Reduces gastric
secretion and
increases gastric
mucus and
bicarbonate
production, creating
a protective coating
in gastric mucosa.

Indication/
purposes
Treatment of
active duodenal
ulcer; maintenance
therapy for duodenal
ulcer patient after
healing of acute
ulcer; treatment of
gastro esophageal
Reflux disease:
short-term treatment
of active, benign
gastric ulcer;
treatment of
pathologic GI
hypersecretory
conditions (e.g.,
Zollinger-Ellison
syndrome, systemic
mastocytosis, and
postoperative
hypersecretion);
heartburn.

Clients response

No signs of any
adverse reaction.

Nursing
responsibilities
(Prior, during,
after)
Assess vital signs.
Monitor CBC and
liver function tests.
Assess patient for
epigastric or
abdominal pain and
frank or occult blood
in the stool, emesis,
or gastric aspirate.
Inform patient that
it may cause
drowsiness or
dizziness.
Inform patient that
increased fluid and
fiber intake may
minimize
constipation.
Advise patient to
report onset of black,
tarry stools; fever,
sore throat; diarrhea;
dizziness; rash;
confusion; or
hallucinations to
health care
professional
33

promptly.

c. Diet
Type of diet

DAT except dark

colored food

Date started Date

changed/D/C

September 6, 2010

General description

A human being
pattern of
eating.
It simply means
"eat anything
you want
except dark
colored foods.

Indications/Purposes

Any food except dark colored

foods that he desires nutritious,
if this will not lead to any
complications and if the client
needs further monitoring for lab
test

Specific Foods taken

Client response to the

diet

All nutritious food

except dark colored
foods such as
chocolates, dinuguan,
squid, etc.

The patient obeys and

maintained the
instructed diet.

34

d. ACTIVITY/ EXERCISE
TYPE OF EXERCISE

DATE ORDERED/
DATE STARTED/
DATE
DISCONTINUED

GENERAL
DESCRIPTION

INDICATIONS/
PURPOSES

CLIENTS
RESPONSE TO
ACTIVITY

NURSING
RESPONSIBILITIES

Regular physical activity

September 6, 2010

important for
maintaining physical
fitness and can
contribute positively
to maintaining a
healthy weight,
building and
maintaining healthy
bone density, muscle
strength, and joint
mobility, promoting
physiological wellbeing, reducing
surgical risks, and
strengthening the
immune system.

-improve the range of

motion of muscles and
joints.

The patient can

regain the strength
he has lost in the
days of his
hospitalization

-explain to the patient the

importance and benefits of
having a regular exercise.

- increasing
cardiovascular
endurance.

-encouraged the relative or

family to join in the activity.
-give some exercises that the
patient can do that cant
cause him any stress.

35

NURSING CARE PLAN

CUES

Subjective:
Nahihilo,
nanghihina at
sumasakit ang tiyan
ko as verbalized by
the patient.

Objective:

Pallor

Hemoglobin =
100 g/L

Hematocrit =
0.330 L/L

NURSING
DIAGNOSIS

SCIENTIFIC
KNOWLEDGE

Ineffective Tissue
Perfusion r/t
Decreased
hemoglobin
concentration in
blood AEB low
hemoglobin
concentration, pallor
and dizziness, and
muscle weakness.

Typhoid Ileitis &

DHF

Definition:
Decrease in oxygen
resulting in the
failure to nourish
the tissues at the
capillary level
[Tissue perfusion
problems can exist
without decreased

Viral infection

Decreased CBC &

platelet count

Decreased level of
hemoglobin and
hematocrit

Decreased blood
oxygenation

GOALS/
OBJECTIVES

NURSING
INTERVENTION

After 12 hours of 1.
nursing intervention,2. 1. a.) Encourage
the client will be
patient to take
able to:
iron
supplements and
1. Demonstrate
eat foods rich in
different ways to
iron.
improve blood
b.) Elevate head of
oxygenation and
bed to about 10
circulation.
degrees.
2. Verbalize
understanding of
condition and
importance of
treatment
regimen.
3. Demonstrate
increased tissue
perfusion.

RATIONALE

c.) Discourage
strenuous
activities.
2. a.) Provide health
teaching
regarding DHF
and Typhoid
Ilietis
b.) Provide health
teaching on
drugs being

EVALUATION/
EXPECTED
OUTCOME

1. a.)To help
After 32 hours of
elevate
nursing intervention
hemoglobin and the client was:
hematocrit levels
1. Demonstrated
different ways to
improve blood
b.) To promote
oxygenation and
circulation and
circulation.
venous drainage.
2. Verbalized
c.)To avoid
understanding of
increased oxygen
condition and
demand.
importance of
treatment
2. a.) To help client
regimen.
understand his
health condition.
b.)To maintain
compliance to
meds.

3. Demonstrated
increased tissue
perfusion

36

cardiac output;
however there may
be a relationship
between cardiac
output and tissue
perfusion.]

taken.
pallor, dizziness,
muscle weakness

Ineffective tissue
perfusion

Source:
Nurses Pocket
Guide Ninth Edition

3.
a.) Monitor vital
signs
.
b.) Encourage early
ambulation
when possible.

3.

a.)Serve as
basis for any
alteration in
system functions.

b.) Enhances
venous return.

Collaborative:
Administer
medications as
ordered
Administer and
regulate IVF as
ordered
Administer packed
RBCs
Monitor lab studies
( Hb,Hct, RBC count)

Help
control/alleviate
symptoms
Maintain
hydration and help
wash away toxins
Packed RBCs are
adequate for stable
patients with
subacute/chronic
bleeding to
increase oxygen
carrying

37

capability.
Aids in
establishing blood
replacement needs
& monitoring
effectiveness of
therapy.

Source:
Nurses Pocket Guide
Ninth Edition

Source:
Nurses Pocket
Guide Ninth Edition

CUES

NURSING
DIAGNOSIS

SCIENTIFIC KNOWLEDGE

GOALS/
OBJECTIVES

NURSING

RATIONALE

INTERVENTION

EVALUATION/
EXPECTED
OUTCOME

Infectious agents (pyrogens)

Subjective:
Mainit ang
pakiramdam
ko
as verbalized
by

Hyperthermia
related to
inflammatory
response as
manifested by
body temperature
of 38.6 degree

Monocytes

Pyrogenic cytokines

After 4 hrs. Of
nursing
interventions,
the patient will
maintain core
temperature
within normal

Independent:
Rendered tepid
sponge bath

To promote
cooling surface

Encouraged to
increase fluid intake

To replace fluid
loss due to body
heat

Promoted surface

Heat is loss by

After 4 hrs. Of
nursing
interventions, the
patient was able
maintain core
temperature within
normal range.

38

the patient.
Objective:
Flushed skin,
warm to
touch.

Celsius, flushed
and warm to touch
skin.

Anterior hypothalamus

Elevated thermoregulatory set point

Increased Heat

Restlessness

Goal met.
cooling, loosen
clothing, and cool
environment

evaporation and
conduction

Encouraged
to have
adequate
bed rest

To reduce
metabolic
demands

Dependent:

V/S taken as
follows:
T: 38.6 C
P: 78
R: 19
BP: 110/80

range.

conservation(Vasoconstriction/behaviour
changes) Increased Heat production
(involuntary muscular contractions)

F EVER

Administered
Paracetamol
as ordered

To decrease
temperature

Administered IVF
as ordered

To support
circulating
volume and
tissue
perfusion

39

CUES
Subjective:
Palagi akong
nauuhaw, as
verbalized by the
patient
Objective:
> Decreased platelet
count= 69L
>Thirst
>Weakness

NURSING
DIAGNOSIS
Diagnosis:
Risk for deficient
fluid volume related
to decreased blood
volume secondary to
altered platelet
production
Definition:
The state in which an
individual is at risk
of experiencing
vascular, cellular, or
intracellular
dehydration

SCIENTIFIC
KNOWLEDGE
Recognition of
dengue viral antigen
on infected
monocyte by
cytotoxic cells

Cellular direct
destruction

Infection of red bone

marrow precursor
cells

Immunological
platelet survival

Platelet lyses

Hemorrhage

Increasing the risk

for fluid volume
deficit

PLANNING
Short Term:
After 1 hr. of nursing
interventions, the
client will be able to
demonstrate
behaviors that reduce
the risk of decreased
fluid volume as
manifested by:
>

Increased oral

fluid intake.
>

Enumerate ways

to prevent
bleeding

NURSING
INTERVENTION
Independent:
> Note possible
conditions like
fluid loss and
limited intake.
>

Monitor I&O

RATIONALE
>These conditions
may lead to fluid
deficits
>To ensure
accurate picture of
fluid status

> Monitor VS
changes.

>Water loss can

directly affect the
body system

> Assess the signs

and symptoms of
GI bleeding. Check
for secretions.
Observe color and
consistency of
stools or vomitus.

>The GI tract is the

most usual source
of bleeding of its
mucosal fragility

> Observe for

presence of
petichiae,
ecchymosis,
bleeding from one

>Su-acute
disseminated
intravascular
coagulation may
develop seondary to

EVALUATION
Short term:
Goal Met.
After 1 hour of
nursing
interventions, the
client was able to
demonstrate
behaviors that reduce
the risk of decreased
fluid volume.
.> Increased oral
fluid intake.
> Enumerate ways
to prevent
bleeding

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more sites.

altered clotting
factor

> Encourage use

of soft toothbrush.
Avoid straining in
stool, and forceful
nose blowing.

>Minimal trauma
can cause mucosal
bleeding

> Monitor lab

studies ( Hb,Hct,
RBC count,
platelet, PTT,
APTT)

>Aids in establishing
blood replacement
needs & monitoring
effectiveness of
therapy.

> Encourage water

for thirst instead of
juices or soda..

>Juices or soda are

more concentrated
and has lesser water
content.

> Promote intake

of high-water
content foods (e.g.
popsicles, gelatin,
eggnog, watermelon)

>Adds water in the

diet without
overwhelming the
client with bulk of
drinking water.

Collaborative:
> Provide/ assist in >To replenish fluid
volume for severe
giving
dehydration
supplemental
fluids as indicated
(e.g. parenteral,

41

enteral)

VI.

DISHARGE PLANNING

METHODS
MEDICATION:

Continue taking prescribe medication for the patient on exact dosage, time, and frequency making sure that the purpose of the medication is truly discussed
by the health care provider.

Instruct the patient to follow the instruction when administering meds.

Advice the significant others not to leave the patient during meds.

Advice the patient not to stop intake of prescribed meds, unless approved by the physician.

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 health. Remind about the need for health promotion activities such as reading, watching T.V, etc.

TREATMENT:

Bed rest is advisable during the re-occurrence of fever phase.

42

Instruct to drink plenty of water or fluids that are available at home and eat nutritious diet.

Advised to look for re-occurrence of danger signs and symptoms and report immediately.

HYGIENE:

Encourage to continue the routinely hygienic care of the patient

OPD:

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.

DIET:

Instruct the family members to give the client protein rich foods such as meat, fish, eggs and dairy products.

VII.

CONCLUSION
As part of our requirement, we had learned so much in handling our client who DHF. We attained and follow certain standards and rules to promote

nurse patient interaction. With this case study, we gain knowledge that we can surely use in the future ahead. All we do to our client is the summary of what
we have learned in lectures in school. We also share some information with our client like the main probable cause and the risk factors of having DHF. We
do manage our time to give sufficient care to our beloved client. We believed that client is our work and we have the responsibility to attend to their needs

43

and serve them as best as we can. We are able to provide health teaching about the proper health care to our client with DHF. We started having an interview
by building trust to our client because at first, he wasnt like to share some information to us. But, as time goes by, we were able to let our client share some
information that will be very useful in this case studies.
VIII. BIBLIOGRAPHY
Schull, Dwyer Patricia, Nursing Spectrum DRUG Handbook, The McGraw-Hill Companies, Inc. copyright 2008
Wilkinson, Judith M, and Nancy R. Ahern, Nursing Diagnosis Handbook 9th edition, Pearson Education South Asia Pte. Ltd copyright 2009
Kozier, Barbara; Avory Berman; Glenora Erb and Shirlee Snyder, Fundamentals of Nursing 7th Edition, Pearson Education South Asia Pte. Ltd. Copyright
2004
Colbert, Bruce J; Jeff Ankney and Karen T. Lee, Principles of Anatomy & Physiology, an interactive journey, Pearson Education South Asia Pte. Ltd.
Copyright 2007
Walker, Richard Guide to the HUMAN BODY, Octopus Publishing Group Ltd. Copyright 2003
Delaune, Sue E. and Patricia K. Ladner, Fundamentals of Nursing, Standards and practice, 3rd edition, Thomson learning Asia,Copyright 2006
Nursing 2006 Drug handbook 26th edition, Lippincott Williams and wilkins
Deglin, Judith Hopper and April Hazard Vallerand, Daviss Drug Guide for Nurses, 9th edition
Nurses Pocket Guide: Nursing diagnoses with interventions 4th edition
Brunner & Suddarths, Medical and Surgical Nursing 10th edition, Lippincott Williams & Wilkins Copyright 1996

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