` `

A Case Analysis on:

Dengue Fever with Pleural
Effusion

Presented to:
Dr. Maria Theresa Belciña Jr.

Prepared by:
Angel Clyla Amit, SN
TABLE OF CONTENTS
Letter for Application
Mission and Vision
Objectives
Acknowledgement
Introduction
I. Psychosocial Profile
A. Demographic Data Genogram
B. Growth and Development
II. Anatomy and Physiology
Pathophysiology
 III. Medical Management
A. Drugs and Treatment
B. Laboratory and Diagnostic Exams
C. Procedures
IV. Nursing Care Management
A. FHP
B. NCP
C. Summary of Nursing Diagnoses
Including High Risks
V. Annotated Readings
VI. Bibliography
February 2018

Dr. Maria Theresa Belciña Jr., RN

Clinical Instructor, Pediatrics Rotation-IP
College of Nursing, Silliman University
Dumaguete City

Dear Dr. Belciña,

I, Angel Clyla Amit, level IV section IP- Belciña student of Silliman University College of Nursing in the Pediatrics rotation, would like to apply on a case study of
our patient, Ms. Z.M.S.T., 2 years old from Cangmunag, San Juan, Siquijor , admitted to SUMC Pediatrics Department last February 2, 2018 with a diagnosis of
Dengue Fever with pleural effusion. This case study would provide comprehensive information regarding our patient and will surely enhance our knowledge, skills
and capabilities as future nurses.

We will assure to you that patient’s confidentiality will be kept, and the data gathered will be used for educational purposes only. In this way, we could further
share our knowledge to our fellow classmates throughout the case presentation.
We are hoping for your kind consideration. Thank you very much!

Sincerely yours,

Angel Clyla Amit

Approved by:

Dr. Maria Theresa Belciña Jr, RN, MSN, PhD

Clinical Intructor
 VISION

A leading Christian institution committed to total human development for the well-being of
society
and environment.

MISSION

• Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ.
• Provide an environment where Christian fellowship and relationship can be nurtured and
promoted.
•Provide opportunities for growth ad excellence in every dimension of the University life in
order to strengthen character, competence and faith.
•Instill in all members of the University community an enlightened social consciousness and a
deep sense of justice and compassion.
•Promote unity among peoples and contribute to national development.
OBJECTIVES OF CASE STUDY
Topic Description

This case study deals on the care given to the female patient during her stay in the Silliman University Medical Center – Pediatrics department. The
anatomy and physiology of the involved organs, and as well as the physical assessment of the patient will be discussed and explored in this study. This study also
includes the pathophysiology, functional health pattern using Gordon’s FHP Tool as well as the holistic care given to the patient. This case study aims to further
enhance our knowledge on Dengue Fever with pleural effusion and how to properly deal with these conditions as a nursing student.

Case Study Objectives: Our objectives for our case study are the following:

1. To further broaden our knowledge on the said disease conditions of the patient.
2. To explain the process of how the diseases develops.
3. To incorporate our knowledge learned during our lectures, ward classes, and conferences into the actual hospital setting.
4. Research more on the disease conditions to supplement the knowledge we gained from lecture discussions.
5. To discuss the applied learned medical procedures done in the actual hospital setting.
6. Identify the developmental stage of the client and check if she has accomplished her developmental tasks.
7. Discuss the anatomy and physiology of the cardiovascular system, integumentary system, and endocrine
system that are very much affected with regards to the diseases.
8. Analyze the physical and psychological changes of the patient.
9. Develop appropriate nursing interventions for each stage to promote patient’s comfort.
10. Gain knowledge about Dengue Fever with Pleural Effusion
11. Learn about the pathophysiology of diseases.
12. Discuss the complications and causes of the said disease conditions.
13. Discuss the preventive and curative aspects of the disease conditions.
Case Presentation Objectives: Within our 1-hour case presentation, the learners will:

1. Review related concepts on previous lectures covered in Nursing Care Management

2. Discuss the process of how the disease conditions develops

3. Explain the pharmacodynamics of the medications given to the patient.

4. Identify the physiological and psychological changes associated with the diseases.

5. Analyze critically the nursing care plans.

6. Participate in the open forum.

INTRODUCTION
The body is one of the most amazing things that ever existed in this world. Every living creature, and even to some that are not breathing, almost everything that
is seen by our naked eyes has a body. It is composed of very minute cells which make up most of it – even cells have parts of their own. It has different defense
mechanisms that protect it from harvesting the pathogens and succumbing to the diseases that it causes. It also has the other mechanisms that sustain its life,
and excrete microorganisms and other toxins that crossed the primary defenses and entered the body.

With the knowledge that I have regarding how our body responses to the different pathogens, I somehow have
the responsibility of educating our patients with the factors that could lead them to possibly acquiring different
diseases brought about by infectious agents.

This presentation is based on my client who has been diagnosed with Dengue fever with pleural effusion. It will
tackle on the pathophysiology of the disease condition and how it had affected the patient’s physiological
functioning. It will also cover on the anatomy and physiology of the organs affected, the medications taken by the
patient, and P. A. results of my patient. This presentation also discusses the nursing process in the care of the
patient with dengue fever.
 I. DEMOGRAPHIC DATA

Name: Z. M. S. T Civil Status: Single Sex: Female Educational Attainment: : N/A

Address: Cangmunag, San Juan, Siquijor_ Religion: Roman Catholic Age: 2 Occupation: N/A

Room and Bed No.:435-A Doctor(s) in Charge:ADCinco Nationality: Filipino

Date and Time of Admission: February 2, 2018 at 8:17 p.m

Chief Complaints: Cough & Fever

Diagnos(es): _Dengue Fever with Pleural Effusion

General Impression of client (appearance upon first contact):

During initial contact with px she was awake, alert and responsive. However ], showed withdrawal from nurses. She had
D5IMB running well @R metarcapal vein and O2 @2L/min . she was appering to be in labored breathing with non-pruritic rashes on legs
and arms, appears slightly sweaty and oily
 47 y/o  45 y/o
 Fisherman  housewife

 2 y/o
 18 y/o

C. GROWTH AND DEVELOPMENT
ZMST’s weight is 11.4 kg, height is 84 cm, Head circumference is 46 cm and abdominal circumference is 47 cm.

The term terrible twos has often been used to describe the toddler years, the period from 1 to 3 years old (12-36 mos.). It is a time of intense exploration of the
environment as children attempt to find out how things work and how to control others through temper tantrums, negativism, and obstinacy. Although this can
be a challenging time for parents and child as each learns to know the other better, it is an extremely important period for developmental achievement and
intellectual growth.

Z.M.S.T belongs to this age group. She is very active and curious. She has temper tantrums. When she is frustrated she throws things but mother is able to
discipline her.

DEVELOPMENTAL MILESTONE

The major gross motor skill during the toddler years is the development of locomotion. At age 2 years, toddlers can walk up and downstairs using both
feet and same step at the same time and by age 2.5 years they can jump, using both feet, stand on one foot for a second or two and manage a few steps on
tiptoe. Fine motor development is demonstrated in increasingly skillful manual dexterity. By 2 years of age toddlers use their hands to build towers and can open
doors by turning door knobs, and unscrew lids. Mastery of gross and fine motor skill is evident in all phases of the child’s activity such as play, dressing, language,
and comprehension, response to discipline, social interaction and propensity to injuries.

ZMST is able to walk, she can remove clothing on her own, able to communicate with others and follows when being disciplined.

EMOTIONAL DEVELOPMENT:

• Developmental Task: Autonomy versus Shame and Doubt

 According to Erick Erickson (1993), the developmental task of toddlerhood is acquiring a sense of autonomy while overcoming a sense of doubt and
shame. Several characteristics, especially negativism and ritualism, are typical of toddlers in their quest for autonomy. As toddlers attempt to express their will
they often act with negativism. The words “No” or “Me Do!” can be sole vocabulary. Emotions become very strongly expressed, usually in rapid mood swings. One
minute, toddlers can be engrossed in an activity and the next minute they might be violently angered. If scolded for doing something wrong, they can have a
temper tantrum and almost instantaneously pull at the parent’s legs to be picked up and comforted. In contrast to negativism, which frequently disrupts the
environment, ritualism, the need to maintain sameness and reliability provides a sense of comfort. Toddlers can venture out with security when they know that
familiar people, places, and routines still exist.

ZMST has achieved this developmental task. She frequently says no and has temper tantrums when frustrated. She is very comfortable around her mother. She is
afraid when nurses and other hospital personnel are around. When hospital procedures are done she always says no. However, she always finds comfort when
mother and father is around.

COGNITIVE DEVELOPMENT

The period from 12 -24 months of age is a continuation of the final two stages of the sensory motor phase. During this time the cognitive processes
develop rapidly and at times seem similar to those of mature thinking. However, reasoning skills are still quite primitive and need to be understood to effectively
deal with the typical behaviors of a child of this age. In stage 5 – Tertiary circular reaction (12-18 mos.), a toddler is described as a “little scientist”. In stage 6 –
Invention of New Means through Mental Combination (18 – 24 mos.) where toddlers are able to try out various actions mentally rather than having to actually
perform them. One of the most dramatic achievements is in the area of complete object permanence. There is a greater symbolization of imitation. The child is
acutely aware of others’ actions and attempts to copy them in gestures and in words which can be classified to as Domestic mimicry which is imitating household
activities.

ZMST exhibits domestic mimicry by imitating household activities like sweeping and cooking.
SOCIAL DEVELOPMENT

A major task of the toddler period is differentiation of self from significant others, usually the mother. Differentiation consists two phases. The
separations emerge from symbolic fusion with the mother. Individuation marks the children’s assumption of their individual characteristics in the environment.
Toddlers show less fear of stranger when parents are present but when left alone with the stranger they become very fearful and acutely anxious.

ZMST is very anxious around strangers but gets comfortable and secure when mother is around.

Language

Toddlerhood is a critical time for language development. More striking characteristic is the increasing level of comprehension. At 2 years
approximately 300 words can be spoken and uses multiword sentences by stringing together two or three words. They have the ability to comprehend and
understand speech is much greater than the number of words the child can say.

ZMST is able to comprehend and understand when she is being talked to. She has the ability to communicate and her speech is understandable according to
mother.

Play

This magnifies the toddler’s physical and psychosocial development. Interaction with people becomes increasingly important. The solitary play of
infancy progresses to parallel play where the toddler plays alongside, not with, other children.

ZMST plays together with neighbors and siblings

ANATOMY AND
PHYSIOLOGY
The Cardiovascular System
The cardiovascular or circulatory system is responsible primarily with the movement of blood in the body. It also plays an important role in the maintenance of
homeostasis, immune response and the transport of fluids. It is composed of tubes that serve as passage of fluids to and away from the heart and the different
components of blood.

Arteries are the vessels that transport fluids away from the heart. Arteries carry oxygenated blood. In the past they were found to be empty on dead
people thus give the name. From the words Aer= hollow Tereo= to carry. The hollow center is called the lumen. It is made up of three main layers. The tunica
externa as the outermost layer, tunica media as the middle layer and tunica intima as the inner layer. The structure of the arteries gives them two special
properties----- elasticity and contractility. As the ventricles of the heart start to eject blood, the arteries expand to accommodate the extra blood. Then as the
ventricles start to relax, the elastic recoil of the arteries forces blood onward. The contractility of the artery comes from the smooth muscles arranged
longitudinally and the rings around the lumen. These muscles are stimulated by the sympathetic nervous system to cause vasoconstriction and vasodilation.

The microscopic capillaries are the smallest blood vessels. Their exceedingly thin walls consist of a thin tunica intima. They are found near everybody cell
and are distributed according to oxygen demands. The primary function of the capillary is to permit nutrient, waste, and gas exchange between the blood and the
tissue cells. This exchange occurs only in capillary wall since the other blood vessels have thick walls presenting a great barrier for exchange.

Veins are composed essentially of the same three coats as arteries, but they have variations in thickness. Despite the difference the vein is still able adapt
to the changes volume. By the time blood leaves the capillaries and flows into the vein, its pressure I s greatly decreased. This decrease in pressure is what caused
its difference from the artery. Some veins have valves to prevent backflow of unoxygenated blood due to the decrease in pressure.

The blood is a connective tissue suspended in a liquid matrix called plasma. Suspended also in this matrix are formed elements------ cells and cell fragments.
Plasma is a straw colored liquid that consists of mostly water (91.5%) and a variety of dissolved substances (nutrients, wastes, enzymes, hormones, respiratory
gases, and ions). Formed elements are red blood cells (erythrocytes), white blood cells (leukocytes), and platelets (thrombocytes). Plasma consists about 55% of
whole blood and 45 % formed elements. Seven % of the dissolved components in blood plasma are proteins. Some proteins in plasma are also found elsewhere in
the body. However, those confined in blood are called blood proteins. These proteins are important in the maintenance of osmotic pressure, which is important in
total body fluid balance.
The liver, including albumins (54% of plasma proteins), globulins 38% and fibrinogen 7%, synthesizes most plasma proteins. Other solutes in plasma include waste
products such as urea, uric acid, creatinine, ammonia, and bilirubin; nutrients; vitamins; regulatory substances such as enzymes, hormones and electrolytes.
Formation of Blood Cells
The process by which blood cells are formed is called hemapoiesis or hematopoiesis. During the embryonic stage of life there are several centers for
production. The yolk sac, liver, spleen, thymus gland, lymph nodes, and bone marrow will all participate at various times in producing formed elements. After
birth however, hematopoiesis occurs only in the red marrow (myeloid tissue). Red bone marrow is found in the proximal epiphysis on the humerus and femur,;
flat bones such as the sternum, ribs and cranial bones; and the pelvis.
Stem cells which give rise to differentiated blood cells and also replenish themselves reside mainly in the red marrow, Although few circulate in the blood.
Five types of cells develop from pluripotent hematopoietic stem cells (hemocytoblasts), which are derived from the mesenchyme.

1. Proerythroblasts ( rubiblasts) form erythrocytes

2. Myeloblasts- form mature neutrophils, eosinophils, and basophils.
3. Monoblasts- form mature monocytes
4. lyphoblasts – form mature lymphocytes
5. Megakaryoblasts- form platelets or thrombocytes

Several hematopoietic factors stimulate differentiation along particular paths and promote proliferation of certain proginator cells. Erythropoietin or EPO
a hormone mainly by the kidneys and also in small amounts produced by the liver stimulates the formation of erythrocyte precursors and thrombopoietin
stimulate the formation of thrombocytes. In addition there are several cytokines that regulate hematopoiesis of different blood cell types. Cytokines are small
glycoproteins produced by the red bone marrow cells, leukocytes, macrophages and fibroblasts. They act locally as autocrines and paracrines that stimulate
normal cell function and stimulate proliferation. Two important families of cytokines that stimulate blood cell formation are called colony stimulating factors
(CSF’s) and interleukins.

Most growth factors are available through recombinant DNA technology. They hold tremendous potential for medical uses in situations where a person’s ability to
produce blood cells are diminished or ineffective. Recombinant erythropoietin is very effective in diminished erythrocyte production.

Red Blood Cells:

More than 99% of the formed elements in blood are erythrocytes. They contain the oxygen-carrying pigment hemoglobin, which is responsible for the red
color of whole blood.
Red Blood Cell Anatomy:
 Under a microscope, RBC’s appear as biconcave discs averaging about 8 m in diameter. The flexible biconcave shape allows the RBC to squeeze through
the narrow capillaries, which may only be 3 m wide. Mature red blood cells are simple in structure. They lack nucleus and other organelles and can neither
reproduce nor carry extensive metabolic activities. The plasma membrane encloses the hemoglobin, which was synthesized before the loss of the nucleus and
which constitutes about 33% cells weight. Hemoglobin is then dissolved in the cytosol.

Anatomy and Physiology of Platelets

Like red blood cells, platelets are anuclear and discoid; they measure 1.5–3.0 μm in diameter. The body has a very limited reserve of platelets and so they
can be rapidly depleted. They contain RNA, a canalicular system, and several different types of granules; lysosomes (containing acid hydrolases), dense bodies
(containing ADP, ATP serotonin and calcium) and alpha granules (containing fibrinogen, factor V, vitronectin, thrombospondin and von Willebrand factor), the
contents of which are released upon activation of the platelet. These granule contents play an important role in both hemostasis and in the inflammatory
response.

Production
Platelets are produced in the bone marrow; the progenitor cell for platelets is the megakaryocyte. This large, multinucleated cell sheds platelets into the
circulation. Thrombopoietin (c-mpl ligand) is a hormone, mainly produced by the liver, that stimulates platelet production. It is bound to circulating platelets; if
platelet levels are adequate, serum levels remain low. If the platelet count is decreased, more thrombopoeitin circulates freely and increases marrow production.
Circulation
The circulating life of a platelet is 9–10 days. After this it is sequestered in the spleen. Decreased function (or absence) of the spleen may increase platelet counts,
while hypersplenism (overactivity of the spleen, e.g. in Gaucher's disease, leukemia and cirrhosis) may lead to increased elimination and hence low platelet
counts.
Function
Platelets are activated when brought into contact with collagen (which is exposed when the endothelial blood vessel lining is damaged), thrombin (primarily
through PAR-1), ADP, with receptors expressed on white blood cells or the endothelial cells of the blood vessels, among other activators. Once activated, they
release a number of different coagulation factors and platelet activating factors. Platelet activation further results in the scramblase mediated transport of
negatively charged phospholipids to the platelet surface. These phospholipids provide a catalytic surface (with the charge provided by phosphatidylserine and
phosphatidylethanolamine) for the tenase and prothrombinase complexes. The platelets adhere to each other via adhesion receptors or integrins, and to the
endothelial cells in the wall of the blood vessel forming a haemostatic plug in conjunction with fibrin. The high concentration of myosin and actin filaments in
platelets are stimulated to contract during aggregation, further reinforcing the plug. The most common platelet adhesion receptor is glycoprotein (GP) IIb/IIIa; this
is a calcium-dependent receptor for fibrinogen, fibronectin, vitronectin, thrombospondin and von Willebrand factor (vWF). Other receptors include GPIb-V-IX
complex (vWF) and GPVI (collagen)
Activators
There are many known platelet activators. They include
• Collagen, especially with von Willebrand factor which is exposed when endothelial blood vessel lining is damaged and binds to GPVI on the platelet;
• Thrombin, primarily through cleavage of the extracellular domain of PAR1 and PAR4;
• Thromboxane A2 (TxA2), which binds to TP;
• ADP through creation of TxA2, which can be blocked by conversion of ADP to cAMP;
• Human neutrophil elastase (HNE) cleaves the αIIbβ3 integrin on the platelet surface;
• P-selectin, which binds to PSGL-1 on endothelial cells and white blood cells; and
• Convulxin, (a purified protein from snake venom) which binds to GPVI.
Inhibitors
• Prostacyclin opposes the actions of Thromboxane A2
• Nitric oxide
• Clotting factors II, IX, X, XI, XII
• Nucleotidases by breaking down ADP
Role in disease
High and low counts
A normal platelet count in a healthy person is between 150,000 and 400,000 per mm3 of blood. 95% of healthy people will have platelet counts in this range.
Some will have statistically abnormal platelet counts while having no abnormality, although the likelihood increases if the platelet count is either very low or very
high.
Both thrombocytopenia (or thrombopenia) and thrombocytosis may present with coagulation problems. Generally, low platelet counts increase bleeding risks
(although there are exceptions, e.g. immune heparin-induced thrombocytopenia) and thrombocytosis (high counts) may lead to thrombosis (although this is
mainly when the elevated count is due to myeloproliferative disorder).
Low platelet counts are generally not corrected by transfusion unless the patient is bleeding or the count has fallen below 5 (x 109/L); it is contraindicated in
thrombotic thrombocopenic purpura (TTP) as it fuels the coagulopathy. In patients having surgery, a level below 50 (x 109/L) is associated with abnormal surgical
bleeding, and regional anaesthetic procedures such as epidurals are avoided for levels below 80-100.
Normal platelet counts are not a guarantee of adequate function. In some states the platelets, while being adequate in number, are dysfunctional. For instance,
aspirin irreversibly disrupts platelet function and hence normal hemostasis; normal platelet function may not return until the aspirin is ceased and new ones,
which may take over a week, have replaced the affected platelets. Similarly, uremia (a consequence of renal failure) leads to platelet dysfunction that may be
ameliorated by the administration of desmopressin.

Diseases
Disorders leading to a reduced platelet count:
• Thrombocytopenia
o Idiopathic thrombocytopenic purpura
o Thrombotic thrombocytopenic purpura
o Drug-induced thrombocytopenia, e.g. heparin-induced thrombocytopenia (HIT)
• Gaucher's disease
• Aplastic anemia
Disorders leading to platelet dysfunction or reduced count:
• HELLP syndrome
• Hemolytic-uremic syndrome
• Chemotherapy
•
Disorders featuring an elevated count:
• Thrombocytosis, including benign essential thrombocytosis (elevated counts, either reactive or as an expression of myeloproliferative disease); may
feature dysfunctional platelets
Disorders of platelet adhesion or aggregation:
• Bernard-Soulier syndrome
• Glanzmann's thrombasthenia
• Scott's syndrome
• von Willebrand disease
Disorders of platelet metabolism
• Decreased cyclooxygenase activity, induced or congenital
• Storage pool defects, acquired or congenital
 INTEGUMENTARY SYSTEM
The skin is the body's largest organ, covering the entire outside of the body and weighing approximately six pounds. In addition to serving as a protective shield against heat,
light, injury, and infection, the skin also regulates body temperature, stores water, fat, and vitamin D and can sense painful and pleasant stimulation.

Throughout the body, the skin's characteristics vary (i.e., thickness, color, texture). For instance, the head contains more hair follicles than anywhere else, while the soles of the
feet contain none. In addition, the soles of the feet and the palms of the hands have much thicker layers.

The skin is made up of the following layers, with each layer performing specific functions: epidermis, dermis, and fat layer.

The epidermis is the thin outer layer of the skin. The epidermis itself is made up of three sub-layers:

•Stratum corneum (horny layer)

This layer contains continually shedding, dead keratinocytes (the primary cell type of the epidermis). The
keratin, a protein formed from the dead cells, protects the skin from harmful substances.

•keratinocytes (squamous cells)

This layer contains living keratinocytes (squamous cells), which help provide the skin with what it needs to
protect the rest of the body.

•Basal layer

The basal layer is the inner layer of the epidermis, containing basal cells. Basal cells continually divide, forming
new keratinocytes and replacing the old ones that are shed from the skin's surface.

The epidermis also contains melanocytes, which are cells that produce melanin (skin pigment).

The dermis is the middle layer of the skin. The dermis is made up of the following:

•blood vessels
•lymph vessels

•hair follicles

•sweat glands

A protein called collagen, made by fibroblasts (skin cells that give the skin its strength and resilience), holds the dermis together. This layer also contains pain and touch
receptors.

The sub cutis is the deepest layer of skin and is also known as the subcutaneous layer. The sub cutis, consisting of a network of collagen and fat cells, helps conserve the body's
heat while protecting other organs from injury by acting as a "shock absorber."
 RESPIRATORY SYSTEM

It is the function of the respiratory system to transport gases to and from the circulatory system. The respiratory system involves both External and Internal
respiration. External Respiration is the exchange of gases between the atmosphere and the blood. Internal Respiration is the exchange of gases between the
blood and the cells of the body. Cellular Respiration or Aerobic Respiration involves the use of oxygen to break down glucose in the cell. We will examine the
structures and mechanisms that carry oxygen to the cells for use in aerobic respiration and that eliminate the carbon dioxide that is produced by the same
process.

Respiration is a vital function of all living organisms. Respiration occurs at two different levels. The level of the cell, in the mitochondria of eukaryotic cells, aerobic
respiration requires oxygen to break down glucose, releases carbon dioxide, and produces large amounts of ATP. This level of respiration is called internal
respiration or cellular respiration. An organism must get oxygen into its cells and carbon dioxide back
out. This level of respiration is called external respiration because the exchange of gases. The exchange
of gases, oxygen and carbon dioxide between the air and blood. A respiratory system is a group of
organs working together of bring about the exchange of oxygen and carbon dioxide in the environment.
Each cell consumes oxygen and produces carbon dioxide. Large multicellular organism must have a
respiratory system to ensure the effective exchange of gasses with the atmosphere quickly and
efficiently to survive.

The human respiratory system consists of the nose, nasal cavity, pharynx, larynx, trachea, smaller
conducting passages (bronchi and bronchioles) and lungs. The respiratory system may be divided into
the upper respiratory tract (consist of parts outside the chest cavity) composed of the nose, nasal
cavities, pharynx, larynx, and the upper trachea. The lower respiratory tract consists of the trachea and
the lungs themselves.

Air enters the respiratory system through the mouth or nose. Air entering the nose passes into the nasal
cavity. The Nasal Cavity is richly supplied with arteries, veins, and capillaries, which bring nutrients and water to its cells. As air pushes back from the nasal cavity,
it enters the pharynx. The Pharynx is located in the back of the mouth and serves as a passageway for both air and food. When food is swallowed, a flap of
cartilage, called the epiglottis, presses down and covers the opening to the air passage. From the pharynx, the air moves through the larynx, the upper end of the
trachea, and into the trachea that leads directly to the lungs. These passageways provide a direct connection between the outside air and some of the most
delicate tissue in the body. These passageways must filter out dust, dirt, smoke, bacteria, and a variety of other contaminants found in air. The first filtering is
done in the nose. The nose will do three things as we breathe in: 1.filter the air 2.warm the air 3.provide moisture. As air passes through the nasal cavities it is
warmed and humidified, so that air that reaches the lungs is warmed and moist. The Nasal Airways are lined with Cilia and kept moist by mucous secretions. The
combination of cilia and mucous helps to filter out solid particles from the air warm and moisten the air, which prevents damage to the respiratory tissues. The
moisture in the nose helps to heat and humidify the air, increasing the amount of water vapor the air entering the lungs contains. This helps to keep the air
entering the nose from drying out the lungs and other parts of the respiratory system.

At the top of the Trachea is the larynx (Voice Box or Adam's apple). Inside and stretched across the larynx are two highly elastic folds of tissue (Ligaments) called
the vocal cords. Air rushing through the voice box causes the vocal cords to vibrate producing sound waves. At the top of the trachea is the larynx (Voice Box or
Adam's apple). Inside and stretched across the Larynx are two highly elastic folds of tissue (Ligaments) called the vocal. Air rushing through the voice box causes
the vocal cords to vibrate producing sound waves. The walls of the trachea are made up of C-Shaped rings of tough flexible cartilage. These rings of cartilage
protect the trachea, make it flexible, and keep it from collapsing or over expanding. The cells that line the trachea produce mucus; the mucus helps to capture
things still in the air (dust and microorganisms), and is swept out of the air passageway by tiny cilia. Within the thoracic cavity, the trachea divides into two
branches, the right and left bronchi. Each bronchus enters the lung on its respective side. The lungs are the site of gas exchange between the atmosphere and
the blood. The right lung has three. Divisions or lobes, and is slightly larger than the two lobed left lung. The lungs are inside the thoracic cavity, bounded by the
rib cage and diaphragm. Lining the entire cavity and encasing the lungs are pleural membranes that secrete a fluid that decreases friction from the movement of
the lungs during breathing.

The further branching of the bronchial tubes is often called the bronchial tree. Both bronchi and bronchioles contain smooth muscle tissue in their walls. This
muscle tissue controls the size of the air passage. The bronchioles continue to subdivide until they finally end in clusters of tiny hallow air sacs called alveoli. All
exchange of gasses take place in the alveoli. The Alveoli consist of thin, flexible membranes that contain an extensive network of capillaries. The Membranes
separate a gas from liquid. The gas is the air we take in through our respiratory system, and the liquid is blood
OVERVIEW OF THE DISEASE

Dengue result from infection by any of four serotypes of dengue viruses. Transmission occurs through the bite of infected Aedes mosquitoes, principally Aedes
aegypti, which is also the principal urban vector of yellow fever. Hundreds of thousands of cases of dengue and DHF are reported each year in tropical regions of
the Americas, Africa, Asia and Oceania. From 1980 through 1987, 879 632 cases of dengue were reported to the Pan American Health Organization from countries
in the American region. Outbreaks of the more severe form of dengue, DHF, occurred in Cuba in 1981 and in Venezuela in 1989. The majority of DHF cases,
however, occur in Southeast Asia. From 1981 through 1986, 796 386 cases of DHF and 9774 deaths caused by dengue were reported to the World Health
Organization (WHO) from countries in Southeast Asia.

History

The early history of dengue is clouded by the similarity of its clinical picture to that of other febrile illnesses. Dengue-like epidemics occurred in Egypt and on Java
in 1779, but these may actually have been caused by chikungunya virus. Dengue or dengue-like epidemics were reported through- out the 19th and early 20th
centuries in the Americas, southern Europe, North Africa, the Middle East, Asia and Australia and on various islands in the Indian Ocean, South and Central Pacific
and the Caribbean. Generally these epidemics consisted of nonfatal febrile illnesses, often associated with rash and either muscle or joint pains. Deaths occurred
during dengue epidemics in Australia in 1897 and in Greece in 1928, when over 1000 deaths were reported. Hemorrhagic manifestations, including
gastrointestinal hemorrhage, were described during dengue epidemics in Texas and Louisiana in 1922. Nevertheless through the first half of the 20th century,
dengue was generally described as a self-limited, nonfatal febrile illness, with occasional hemorrhagic manifestations such as petechiae, epistaxis, gingival
bleeding and menorrhagia, that only rarely resulted in more severe or fatal outcomes.

In 1944 two immunologically distinct but related viruses, now referred to as dengue 1 (DEN-I) and DEN-2, were isolated by Sabin from patients with clinically
diagnosed dengue. In 1956 Hammon et al. and coworkers isolated two new serotypes of dengue viruses, designated DEN-3 and DEN-4, as well as the previously
recognized DEN-I and DEN-2, during epidemics of severe hemorrhagic illness among children in the Philippines. Outbreaks of what came to be known as DHF24
occurred throughout Southeast Asia during succeeding years. The term dengue shock syndrome was coined to describe the cases of DHF with shock, which clinical
studies indicated was caused by increased vascular permeability and resultant intravascular hypovolemia.Eventually the WHO case definition of DHF was modified
to make increased vascular permeability the hallmark of the disease.Cases of severe hemorrhage or even deaths caused by dengue infection that do not show
evidence of increased capillary permeability are not currently classified as DHF according to WHO criteria. The emergence of DHF in the Americas is believed by
some researchers to be following a similar pattern to that seen in Southeast Asia more than 30 years ago. With the reinfestation of many countries in the
American region by A. aegypti, dengue epidemics have recently struck cities and countries in the Americas that had been free of this disease for many years.

Epidemiology

Female A. aegypti mosquitoes acquire the dengue virus by biting an infected human during the viremic phase, which usually lasts for 4 to 5 days but may last up
to 12 days. An extrinsic incubation period in the mosquito of 8 to 10 days must pass before the virus can be transmitted. The extrinsic incubation period is
lengthened by cooler ambient temperatures. After this extrinsic incubation period the
mosquito may transmit the virus during every subsequent feeding of its life.

In most disease-endemic areas dengue transmission has a definite seasonality, but the reasons
for the seasonal patterns are not fully understood. In some areas increases in dengue
transmission coincide with periods of increased rainfall. The interactions between temperature
and rainfall or variations in daily microclimates may be important determinants of dengue
transmission. Cooler temperatures may affect adult mosquito survival, which may also
influence transmission rates. Rainfall and temperature may affect patterns of mosquito feeding
and reproduction. Human behavior, such as the changes in patterns of water storage in
containers, which serve as breeding sites for the mosquitoes, may also affect disease
transmission patterns.

The mechanism by which dengue virus circulation is maintained between epidemics is not fully
understood. Forest cycles of dengue between monkeys and mosquitoes have been described,
but recent techniques of studying molecular evolution in dengue viruses indicate that viruses
from forest cycles in Africa do not represent a natural maintenance reservoir for epidemic
dengue in humans.
Clinical manifestations

The following description of the clinical course of classic dengue infection is based on the work of Riley and Sabin, who observed and described adults with
naturally acquired or experimentally induced infections.

Two to 15 days after the bite of an infective mosquito, the patient typically suffers sudden onset of headache, fever, retroorbital pain, backache, bone and joint
pain, weakness, depression and malaise. Some patients have an evanescent rash over the thorax and joint flexures. There may be flushing of the face and
conjunctivitis as well as taste aberrations, anorexia, nausea, vomiting and abdominal pain. Lymphadenopathy and hepatomegaly may occur but splenomegaly is
infrequent. Patients may complain of sore throat, cough, groin pain, hyperesthesia, dizziness, photophobia, eye pain and, rarely, a "yellow flamelike" color to
objects.

Fever and associated symptoms may subside after 3 or 4 days and the patient may recover completely. Alternatively the decline in fever may be followed 1 to 3
days later by a resurgence of fever and symptoms, giving a "saddleback" appearance to the temperature curve. A second rash, varying in form from scarlatiniform
and maculopapular to petechial and occasionally purpuric, may appear with the initial decline of the fever. Severe itching, especially of the hands and feet, may
accompany this rash, which is sometimes followed by desquamation. The symptoms persist for 1 to 3 days more and then subside with the fever.

During the course of the illness there is often a relative or paradoxical bradycardia in the face of increased temperature. Patients may have hemor- rhagic
manifestations such as epistaxis or menorrhagia. Jaundice is rare. Convulsions may occur with the onset of fever. The spinal fluid is almost always clear with no
elevation of cell count but the pressure may be increased. Depression, weakness and blurred vision may resolve slowly during convalescence. Patients may take
several weeks to recover completely.

Although these symptoms characterize "classical" dengue fever, dengue virus infection may also manifest as a nonspecific febrile illness which can be confused
with influenza, measles or any nonspecific vital syndrome. The lack of a clear clinical pattern for dengue makes laboratory diagnosis a necessary part of any
definitive evaluation of the disease.

The course usually begins with the sudden onset of fever, headache, nausea, vomiting, abdominal pain, pharyngitis, lymphadenopathy and sometimes a rash,
which may be petechial or even ecchymotic early in the course.
The liver may become enlarged and pleural effusions may develop, usually beginning on the right side. As the fever begins to drop around Day 3 to 5, circulatory
instability may develop with signs of decreased peripheral perfusion. Profound shock may follow. Disseminated intravascular coagulation and severe
gastrointestinal hemorrhage have been described.

DIAGNOSIS

Classical dengue fever may be confused with a variety of febrile ill- nesses, including influenza, measles, typhoid fever and malaria. DHF may be confused with
sepsis, toxic shock and any of the viral hemorrhagic fevers including yellow fever. Diseases with specific treatments, such as bacterial meningitis, sepsis, malaria
and Lassa fever, should be ruled out.

Specific diagnosis of dengue infection is made by isolating the virus from the patient's blood. Acute serum samples are inoculated into tissue cultures of mosquito
cells or directly into live Toxorhynchites or Aedes mosquitoes. Isolates can be identified from 2 to 7 days after inoculation depending on the actual technique
used. Viruses are most likely to be isolated from acute serum samples obtained within 5 days after the onset of illness. Specific dengue serotypes can be identified
by the indirect fluorescent antibody test, with the use of type-specific monoclonal antibodies on the isolated virus.

Immunodiagnostic methods for determining dengue infection include detection of anti-dengue IgM and IgG by enzyme-linked immunosorbent assay (ELISA) and
detection of hemagglutination inhibition antibody. Dengue-induced hemagglutination inhibition antibody cross-reacts broadly with other flaviviruses such as
yellow fever and St. Louis encephalitis viruses. Complement fixation and neutralization antibody tests are more specific than hemagglutination inhibition. Most
serologic screening for dengue infection is now done with an IgM ELISA. With appropriately timed samples, the sensitivity and specificity of this test in diagnosing
dengue infection appear to be high. In a review of 131 patients from whom dengue virus was isolated at the Centers for Disease Control, Dengue Branch, 96% of
the 76 samples drawn between 7 and 20 days after the onset of illness were positive by IgM capture ELISA (DJ Gubler, G Kuno, I Gomez, et al. unpublished data). A
study of the performance of IgM ELISA in Thailand showed the sensitivity of this test in convalescent samples to be 97%, and none of the samples from the 2
groups of noninfected controls (98 soldiers and 39 schoolchildren) were positive.

The pattern of HI response has been used to classify dengue infections as primary or secondary, based on the concept that initial, or primary dengue infections
tend to elicit lower HI titers than do secondary infections (subsequent infections with a different dengue serotype or antigenically related flavivirus). IgM:IgG
ratios as determined by ELISA may be an alternative method of distinguishing primary from secondary infections. The rise in neutralizing antibody in primary
infection is believed to be relatively type-specific and can be used to determine the infecting serotype. In secondary infections, because the immunologic cross-
reactivity to different flaviviruses and anamnestic responses may result in heterologous titer elevations, the only reliable method for determining the infecting
serotype is virus isolation.

In summary diagnosis of dengue infection is best accomplished by obtaining an acute serum sample within 5 days after the onset of illness for virus isolation and
antibody testing and a convalescent serum sample 14 to 21 days after illness onset for detecting IgG antibody titer rise and/or the presence of antidengue IgM.

TREATMENT

Treatment for classic dengue fever is supportive. Patients should be encouraged to drink plenty of fluids. Acetaminophen may be taken to control fever and
aching if necessary. Aspirin is contraindicated both because of its anticoagulant effects and the increased risk of developing Reye syndrome. Patients or parents
should be carefully instructed of the need to seek medical attention immediately if major or ongoing hemorrhage, signs of impending shock or any change in
mental status should occur. The onset of cardiovascular collapse in patients who develop DHF may be sudden.

Patients with significant hemorrhage or signs of increased capillary permeability such as hemoconcentration, effusions, edema or low serum albumin, as well as
patients with mental status changes or with abnormal fluid and electrolyte balance, should be hospitalized and may require admission to an intensive care unit.
Isolation is not necessary in mosquito- free environments. Usual precautions handling blood specimens should be observed.

Intravenous fluid therapy is the mainstay of treatment for patients with DHF. Patients with dehydration and hemoconcentration may require intravenous fluids
similar in volume and composition to regimens used to treat dehydration due to diarrheal illness. Patients in shock should be given fluids and other therapy
according to accepted regimens for shock. The administration of heparin may need to be considered in patients who develop DIC.

There is some controversy over the role of steroids in treatment of severe dengue. Studies by Sumarmo et al. showed no benefit, over fluid therapy alone, of
hydrocortisone injection given 30 mg/kg/day or 50 mg/kg in a single dose. The potential effect of high dose methylprednisolone in certain severe cases may need
further evaluation.
 LEGEND

Pathophysiology

Signs and Symptoms

Complications

PATHOPHYSIOLOGY
 DENGUE WITH PLEURAL EFFUSION
RISK FACTORS:

- Tropical environment

Bite of a aedes aegypti

mosquito carrying a virus injects
virus into the epidermis

Virus goes into the dendritic cells and macrophages

Dendrites and macrophages

 Nausea Cytotoxic alarm secrete interferons
 Vomiting
 Diarrhea

Release of natural killer cells

Release of CD4 T cells

Antibodies attach to the viral antigens, and then

monocytes/macrophages will perform phagocytosis
through Fc receptor (FcR) within the cells and dengue virus
replicates in the cells
 Recognition of dengue viral antigen on infected
monocyte
Entry to the bone marrow
Entry to the spleen
Release of cytokines which consist of vasoactive agents
such as interleukins, tumor necrosis factor, urokinase
and platelet activating factors which stimulates WBCs
and pyrogen release

DENGUE

Virus ultimately targets liver and Cellular direct destruction and

 Platelet
spleen parenchymal cells where infection of red bone marrow
126
infection produces apoptosis/cell precursor cells as well as
T/cumm
death immunological shortened platelet

 Abdominal Hepatosplenomegaly thrombocytopenia

pain and
rigidity
Increase number and size of the pores in
the capillaries which leads to a leakage of
fluid from the blood to the interstitial
fluid (capillary leakage

 Cough
 (+) SOB Pleural Effusion
 Coryza
 MEDICAL
MANAGEMENT
 Drugs and Treatment

DR MECHANISM OF ACTION CORR

UGS ELATI
AS ON
OR
DER
ED

Salbu Binds to beta2-adrenergic receptors in airway smooth muscle, leading to activation of adenyl cyclase and increased levels of cyclic-3', 5'- Is given
tamo adenosine monophosphate (cAMP). Increases in cAMP activate kinases, which inhibit the phosphorylation of myosin and decrease intracellular to px
l calcium. Decreased intracellular calcium relaxes smooth muscle airways since she
(Asm • Relaxation of airway smooth muscle with subsequent bronchodilation has
alin) • Relatively selective for beta2 (pulmonary) receptors pleural
1 neb effusion
q8
4a-
12nn
-8p

Ceftr Binds to the bacterial cell wall membrane, causing cell death Is given
iaxon to px
e • Therapeutic Effects:
since
(kept she had
○ Bactericidal action against susceptible
rix) pleural
bacteria
570 effusion
mg
IV • Spectrum:
drip
x 30 • Similar to that of second-generation cephalosporins, but activity against staphylococci is less, while activity against gram-negative
min pathogens is greater, even for organisms resistant to first- and second-generation agents.
q12h
rs
ANS
T (-)
10a-
10p

Ranit Ranitidine competitively blocks histamine at H2-receptors of the gastric parietal cells which inhibits gastric acid secretion. It does not affect Is given
idine pepsin secretion, pentagastrin-stimulated intrinsic factor secretion or serum gastrin. since
(ulci she had
n) abdomi
120 nal pain
mg and
8a- rigidity
8p during
admissi
on
 LABORATORY AND DIAGNOSTIC EXAMS

DATE WITH RESULTS CORRELATION

COMPLETE BLOOD COUNT

2/1/18
A Complete blood count is essential for my px since she has dengue and her
Hemoglobin 9.4 gm% (12-14 gm%) blood values need to be closely monitored
Hematocrit 28.5 % (37-44 %)
WBC 8820 / cumm (4,500-11,000 / cumm)
Segmenters 6% (55-70 %)
Lymphocyte 89 % (20-35 %)
Eosinophil 1% (1-4 %)
Monocyte 4% (1-6 %)
Basophil 0% (0.00-1.00 %)
Platelet 52 T/cumm (150-400 T/cumm)

Red Blood Cell 4.8 M/cumm (4.2-5.4 M/cumm)

Mean Corpuscular Vol 60 Fl (80-96 fL)
Mean Corpuscular Hgb 19.7 pg (27-31 pg)
Mean Corpuscular Hgb Conc 33 % (33-36 %)

Prothrombin time 11.3 sec (10.2-13.0 sec)

Chest X-Ray
Hazy densities in both lungs more on right Chest x-ray is done since px had difficulty breathing and was coughing
Hard densities are seen in the lateral aspect of both hemi-thoraces
 PROCEDURES

PROCEDURES PURPOSE

12/12/16
Platelet and Hct monitoring  To determine any abnormalities and improvements since she has dengue which
affects the platelet and hct.
\

Nursing
Management
 PHYSICAL
ASSESSMENT
GENERAL SURVEY: Seen px, she was awake, alert and responsive. Showed signs of withdrawal from nurses. She had D5IMB running well @ R metacarpal vein, and O2 therapy
via nasal cannula @ 2L/min. She was appearing to be in labored breathing. With non-pruritic rashes on legs and arms.

VITAL MEASUREMENTS:

Temperature- 37.3

Pulse- 103 bpm

Respirations- 33 cpm

Blood Pressure- 100/60 mmhg

HISTORY FINDINGS

No history of measles, mumps, chickenpox. Previously admitted August 2017
for 2 weeks due to cough and fever. No food and drug allergies, no surgeries.
Received BCG-1, Pentavalent-3, OPV-3, PCV-3, MV-1, MMR-1 at local health
center
INTEGUMENTARY SYSTEM:
SKIN: The client’s skin is uniform in color, has maculopapular rash present at
lower extremities.
NAILS: The client’s nails are pinkish in color has the shape of convex curve. It is
smooth and is intact with the epidermis. When nails pressed between the
fingers the nails return to usual color in less than 4 seconds.

HAIR AND SCALP: The client has short thin hair ,brownins-black in color. Hair is
evenly distributed. No deformities, lumps and non-tender upon palpations.
HEAD AND FACE: The head is round; normocephalic and symmetrical. Head is
held upright, no nodules and depressions upon palpation. Face has the same
color of the body, no masses, no involuntary movements and non-tender.

EYES AND VISION:

EYEBROWS: Hair is evenly distributed. The client’s eyebrows are symmetrically
aligned, no presence of scaliness and showed equal movement.. No masses and
non-tender when palpated.
EYELASHES: Eyelashes are equally distributed with curls slightly upward.
EYELIDS: Eyelids are pinkish in color with no presence of discharges, no
discoloration, no masses, not edematous, non-tender when palpated and lids
close symmetrically.
EYEBALLS: The eyeballs are not protruding. Globe is firm and non-tender when
palpated.
LACRIMAL GLAND AND NASOLACRIMAL DUCT: There is no edema, swelling,
redness or tearing of the lacrimal gland. Lacrimal gland and inner canthus of the
eyes is not tender and no presence of any discharges.
VISUAL ACUITY: She doesn’t use correctional glasses.
CONJUCTIVA AND SCLERA: Palpebral conjunctiva appeared pink. Anicteric
schlerae.
CORNEA AND LENS: Cornea is transparent, smooth and shiny and the details of
the iris are visible. Blinks when the cornea is touched.
IRIS: Iris is flat, round and dark brown in color.

PUPILS: Pupils of the eyes are black and equal in size. Constrict when looking at
near object and dilate at far object and converge when object is moved towards
the nose. Pupils are equally round and reactive to light and accommodation.
EARS: Auricles are symmetrical and has the same color with his facial skin. They
are aligned with the outer canthus of the eyes. Ears are symmetrical, not
deformed nor swelling. When palpated for the texture, the auricles are mobile,
firm and non- tender. The pinna recoils when folded.
NOSE AND SINUSES
NOSE: Nose appeared symmetric, straight, uniform in color and not deformed.
There was no presence of discharge or flaring. When lightly palpated, there
were no tenderness and nodules. Nasal mucosa is pinkish in color with evenly
distributed hair, no swelling, no presence of exudates and not bleeding. Nasal
septum is not deviated and not bleeding. Inferior and middle turbinates are
symmetrical not inflamed and no presence of polyps.
SINUSES: Frontal and maxillary sinuses are non- tender.

MOUTH AND NECK

LIPS: Lips is uniformly pinkish in color, dry, symmetric and have a chapped
texture. No nodules, masses, lumps and non- tender when palpated.
ORAL MUCOSA AND GUMS: Oral mucosa and gums are dry. No retraction of
gums and is not bleeding nor inflamed.
TEETH: Teeth are white in color.
HARD PALATE: Pinkish in color, no deformities and irregular in texture
compared to soft palate which is smooth.
TONGUE: Centrally positioned it is pink in color, dry and slightly rough. Floor of
the mouth is pinkish in color and smooth in texture. Tongue is non - tender, no
masses and lumps.
OROPHARYNX: Soft palate rises when the client is instructed to say “AH”.
Tonsils are not enlarged. The uvula is positioned in the midline of the soft
palate. Oropharynx is pinkish, symmetrical with no presence of ulceration and
discharges.
NECK: Neck muscles are equal in size without presence of scars. The client
showed coordinated, smooth head movement with no discomfort. Lymph
nodes are not palpable. Parotid glands are not enlarged. Trachea is placed in
the midline of the neck. Thyroid gland is not visible on inspection and the
glands ascend during swallowing but are not visible.

THORAX, CHEST, LUNG AND ABDOMEN

POSTERIOR CHEST AND ANTERIOR CHEST: The chest wall is intact with no
tenderness, crepitus and masses. There’s a full and symmetric expansion and
the thumbs separate 2cm during deep inspiration when assessing for the
respiratory excursion. The client manifested crackles on both upper lung fields.
Vibrations can be felt at the different parts of the chest when testing for tactile
fremitus. The client manifested crackles on both upper lung fields during
auscultation.
HEART: PMI can be palpated at the apex of the heart. S1 can be heard at the
5th ICS LML and S2 can be hard at the 2nd ICS Right and Left sternal boarder.
There were no visible pulsations on the aortic and pulmonic areas. There is no
presence of heaves or lifts.
BREAST: Color of the breast is the same as the surrounding skin and
symmetrical. Small and convex in shape with protruding upward nipples 1to 2
cm in siz brown in color. No dimpling, discharges, lesions and non- tender
AXILLAE: The axillae have the same color with the surrounding skin with no
lesions and foul smelling odor. No palpable nodes
ABDOMEN: The abdomen has an unblemished skin and is uniform in color.
Globular. Has normoactive bowel sounds and is slightly rigid.
EXTREMETIES: The extremities are symmetrical in size and length with
maculopapular rashes, has lesions on left leg. Had bipedal edema during first
day of admission. But upon assessment patient is no longer edematous.
Extremities are normally firm and showed smooth, coordinated movements.
There were no presence of bone deformities, tenderness and swelling. There
were no swelling, tenderness and joints move smoothly.
 USUAL FUNCTION PATTERN INITIAL APPRAISAL ON-GOING APPRAISAL

I. Health Perception- Health Management I. Health Perception- Health Management I. Health Perception- Health Management
Pattern Pattern Pattern

 s/o claims that px’s general health has been  Admitted due to Dengue fever  Parents claim that px is already feeling well
good  Parents claimed that upon perception of  IV discontinued
 px has all immunizations required for age symptoms such as fever, chills, and restlessness,  O2 discontinued
 px was delivered via NSVD, mother completed they sought professional help  ‘V/S
all required prenatal check-ups  With D5IMB ½L 150 cc running well @right o T: 37
 was admitted twice during entire 2-year metacarpal vein o P: 100
lifetime; the first time was due to fever and  “Gikutasan na man nuon siya human gi hilantan” o R: 20
cough and the second is this admission as verbalized by s/o o BP: 100/60
 client doesn’t adhere to any superstitious forms  “Galisod siya ug ginhawa niya paspas raba gud”  For discharge
of maintaining health As verbalized by s/o  Home meds:
 does not see a physician for routine check-ups  V/S o Cefixime (Tergecef)
unless it is for immunization or admission o 37.3
 parents do not use drugs, alcohol and cigarettes o 103
 px does not encounter major accidents. Only o 33
minor accidents like “madugmo” as stated by o 100/60
s/o which is appropriate for her age since they  With O2 @2L/min via nasal cannula
are trying to master walking.  Medications:
 according to s/o, house is arranged in a way that o Ceftriaxone (keptrix) 570mg IV drip
the px is safe from falls and toxic chemicals for 30 mins q12 (10-10)
o Ranitidine (ulcin) 120mg slow IVTT
q12 (8-8)

II. Nutritional-Metabolic Pattern
 Px is breastfed but is able to tolerate solid food;
prefers to eat rice with “sabaw”
 Takes vitamins supplemental medication
 Mother describes appetite as good. As she
usually consumes her whole share of meal
 Breastfeeds every 3-4 hrs
 Wounds generally heal well
 Does not have skin problems
 weight is 11.4 kg, height is 84 cm, Head
circumference is 46 cm and abdominal
circumference is 47 cm.
 BMI is 16.1 which is within normal range for age
III. Elimination Pattern
 Defecates once a day with stool appearing
yellowish and semi-solid
 Does not have difficulty in defecating
 Mother estimates px urinating at least every 4-5
hrs with urine appearing clear yellow without
o Salbutamol (asmalin) 1 neb q8 (4-12-
8)
 Significant lab results
o Hct 29.5% (37-44%)
o Plt 126 T/cumm (150-400)
II. Nutritional-Metabolic Pattern II. Nutritional-Metabolic Pattern
 Is breastfed by mother almost exclusively during  Mother claims that appetite has greatly
this admission for 5-10 minutes per feeding. improved
Mother has enough milk.  Able to consume 7 oz of milk formula during
 Does not take supplements during admission feeding
 Mother describes appetite as lower than usual  Non-pruritic rashes are absent
 Breastfeeds shortly at about 4hr interval  Absence of bleeding
 Restricted intake of dark colored food  Bowel sounds 8 clicks per minute. Present in all
 There are non-pruritic rashes all over lower quadrants.
extremities
 Weight is 11.4kg
 No lesions or signs of bleeding
 Abdomen is non tender and is slightly distended
 Bowel sounds of 6 clicks per minute. Bowel
sounds present in all 4 quadrants
III. Elimination Pattern
III. Elimination Pattern
 Defecated once during shift around 40-50g
 Was not able to defecate yet since admission yellowish and semi-solid
 Wears diaper during admission for convenience  Changed diapers twice during shift
 Changed diapers twice already upon interview  No abdominal distension
 No signs of excessive perspiration  No urinary problems
 Abdomen slightly distended with bowel sounds
 odor
 Does not wear diapers at home
 Does not perspire excessively
IV. Activity-Exercise Pattern
 Px is bathed once/day with soap and water
usually every morning and half-bath @ night
before sleeping
 Usually plays all-day with siblings and friends
 Plays with toys such as toy guns
 Changes clothes around 6x/day
 Usual activities include waking up, eating
breakfast, plays, bathed by mother, eating
lunch, naps after lunch, plays again, eating
dinner, half-bath before sleeping.
V. Sleep-Rest Pattern
 Px usually sleeps at 8 pm and wakes up at 6 am
 Takes naps @ 10 pm and early afternoon
 Naps at random times during the day
 No problems falling asleep
 No eyebags visible and no dark circles around
 Falls asleep easily when being cradled by mother
VI. Cognitive-Perceptual Pattern
of 6 clicks per minute
 No notable urinary problems
IV. Activity-Exercise Pattern
IV. Activity-Exercise Pattern
 Awake, alert, in a joyous mood
 Awake, alert with responsiveness as aided by  Walks around ward with father
mother  Discontinued o2 therapy
 Mother describes that activities during the  Lung sounds are clear bilaterally
admission include lying down, sleeping, and
feeding
 With 02 @2L/min via nasal cannula
 Upon assessment HR is 103 RR is 33 with slight
coryza
 Reflexes are appropriate for age for both
extremities
V. Sleep-Rest Pattern
V. Sleep-Rest Pattern
 Appears generally well rested
 Slept at 11 pm and woke up at 6 am
 Px appears generally rested
 Sleeps @ around 9 pm and wakes up at 5-6 am
 Disturbed when there are procedures but able
to go back to sleep easily with the help of
mother
eyes.
VI. Cognitive-Perceptual Pattern
VI. Cognitive-Perceptual Pattern
 Px is usually responsive when talked to with
appropriate eye contact
 Px is responding wel when taught basic
commands, actions and speech by mother.
VII. Self-Perception Pattern
 Px according to mother is lively and bubbly
 Px sometimes throws temper tantrums but
calms down when being shown spank by the
mother. This is related to the developmental
task of a toddler which is autonomy vs. shame
and doubt.
 Px has friends and playmates back home
according to mother
VIII. Role-relationship Patern
 Household consists of 5 members
 Usual stressor is financial limitations
 Mother is a housewife while the father is a
fisherman
 Px is close to other members of the family
 Px dependent and finds comfort from mother
which is normal at the age of 2 since children at
this age finds comfort in people they are familiar
with because this reduces their anxiety levels.
 Slightly withdrawn when being asked, only  Responsive and acknowledges presence of
responds to mother nurses
 No report of pain  No report of pain
 Eyes are of normal size, depth of appearance;  Eyes: PERRLA
pupils are round, equal and reactive to light and
accommodation
 Ears are equal bilaterally with no discharges or
foul odor
VII. Self-Perception Pattern
VII. Self-Perception Pattern
 Appears relaxed
 Px appears a bit restless  Plays with nurse and shows affection to parents
 Shows slight withdrawal toward nurses
VIII. Role-Relationship Pattern
VIII. Role-Relationship Pattern
 Parents are relieved because of PCSO grants
 Family is worried with current hospitalization  Brother and parents are present at bedside
because of financial constraints
 Both parents are present during admission
 Px is the youngest child in the family
 Grandparents are left at home to watch over
other siblings at home
 The illness has affected the family since the
father is present in the hospital during admission
 Px actively plays every day with playmates he was unable to go to work and he is the
provider for the family IX. Sexual-Reproductive Pattern
IX. Sexual-Reproductive Pattern IX. Sexual-Reproductive Pattern
 No problems in sexuality reproductive patern
 Parents are not using any form of contraception  No problem with sexuality reproductive pattern
at present  No lumps or masses in the breasts, no
 Px plays with toys for the boys and dislikes girly unusualities on genitourinary tract
toys according to s/o  Clothing is appropriate for gender.
 Parents are not worried about the child’s
sexuality at the moment
X. Coping Stress Tolerance
X. Coping Stress Tolerance X. Coping Stress Tolerance Pattern
 S/O is able to cope with financial stress during
 Parents usually talk about problems until they  Family is looking for ways to pay current hospital admission with the help of PCSO grant
find a solution bill. They are asking for assistance from the
 The lack of money is the main stressor PCSO

XI. Value-Belief Pattern

XI. Value-Belief Pattern XI. Value-Belief Pattern
 Family is thankful to God that px will be
 Parents want the best possible future for their  Prays that they get discharged soon discharged already and that their financial
children  Has a bible on bedside for protection problem is solved.
 Roman catholic
 Does not believe in superstitious beliefs
 COLLEGE OF NURSING
Silliman University
Dumaguete City

Theory: Virginia Henderson Nursing Need theory

Cues and Evidences Nursing Objectives Interventions Rationale Evaluation

Diagnoses
Subjective: Risk for bleeding Within my 2-day care, Independent: Within our 2-day
 “Mura man siya ato ug gi r/t possible the px will not manifest  Educate SO about  Information about care, the goals
dngue mao ng ni anhi mi” impaired liver any signs of bleeding precautionary measures precautionary were met as
function and as evidenced by: to prevent tissue trauma measures lessens evidenced by:
Objective: plasma & platelet or disruption of the the risk for
 Dx of Dengue fever leakage s/t dengue 1. S/O takes normal clotting bleeding 1. S/O verbalized
 V/S fever measures to mechanisms understanding
o T: 37.3 prevent bleeding o Use of soft and
o P: 103 that need to be bristled appreciation of
o R: 33 reported toothbrush measures to
o BP: 100/60 immediately to a o Be careful when prevent
 Labs health care using sharp bleeding
o Hematocrit: professional objects 2. No signs of
29.5% (37-44%) 2. Px does not  Educate about signs of bleeding noted;
o Platelet: 126 experience bleeding that need to be  Early detection all vitals signs
T/cumm (150-400) bleeding as reported and treatment and lab results
evidenced by reduces the risk were within
normal bp, stable for complication normal range
hct and hgb  Instruct SO to check due to blood loss 3. Px was
level, and desired color and consistency of  Bright red blod in discharged
range for stools the stools is an
coagulation indicator of lower
profiles GI bleeding. Dark
greenish-black
colored and tary
consistency is
linked with upper
GI bleeding.
Subjective: Ineffective tissue Within our 2-day care, Independent: Within my 2-day
 “Gikutasan na man nuon perfusion r/t the px will have an  Place px with proper  A siting position care, goal met as
siya human gi hilantan” decreased lung improved breathing body alignment for permits maximum evidenced by:
as verbalized by s/o expansion s/t pattern, as evidenced maximum breathing lung excursion and
 “Galisod siya ug ginhawa pleural effusion by: pattern chest expansion  RR in
niya paspas raba gud” 1. Maintenance of  To clear any normal
As verbalized by s/o an effective  Maintain clear airway by blockage in the range 20
Objective: breathing suctioning secretions as airway cpm, clear
 Diagnosis of pleural pattern, as necessary  Extra activity can lung
effusion evidenced by  Encourage frequent rest worsen shortness sounds,
 V/S relaxed periods and teach s/o to of breath relaxed
o T= 37.3 breathing at pace px’s activities breathing
o P= 103 normal rate and  S/O claims
o R= 33 depth and Dependent: that px is
o BP= 100/60 absence of  Provide respi meds and well-rested
 With o2 @ 2L/min dyspnea O2 as ordered:  Dilates bronchioles  Px was
 (+) SOB 2. RR remains o O2 @2L/min to facilitate easier discharged
 Coryza upon auscultation within normal o Salbutamol breathing
on lung fields limits (Asmalin) 1 neb
 Med: Salbutamol 3. Report of feeling q8
(Asmalin) 1 neb q8 rested

Subjective:
 “nagkamala man iyang Deficient fluid Within our 2-day care, Independent:
panit ug baba katong volume r/t the state of deficiency  Urge px to drink  Oral fluid Within our 2-day
gasugod ug kusog iyang vascular leakage will be minimized as prescribed amount of replacement is care, goal met as
hilanat” as verbalized by s/t dengue fever evidenced by: fluid indicated for evidenced by:
s/o mild fluid
Objective:  Px is normovolemic deficit  V/S are all in
 Dry mucus membranes  Emphasize importance of  Fluid deficit
as evidenced by normal range
 Diagnosis of dengue fever oral hygiene can cause a
 V/S normal v/s dry, sticky  SO verbalized
o T= 37.3  s/o verbalizes mouth. awareness of
o P= 103 Attention to
awareness of causative
o R= 33 mouth care
o BP= 100/60 causative factors promotes factors
 Decreased skin turgor with and corrective interest in  Px was
D5IMB500 ml @20ml/hr measures drinking fluids discharged
and reduces
 s/o explains discomfort of
measures that can be dry mucus
taken to membranes
 Emphasize importance of  Increasing
treat/prevent fluid
maintaining hydration knowledge
volume loss level will assist
in preventing
and managing
the problem
 Dependemt
o D5IMB 500 ml
@20 ml/hr
Deficient fluid volume r/t vascular leakage s/t dengue fever

Ineffective tissue perfusion r/t decreased lung expansion s/t pleural effusion

Risk for bleeding r/t possible impaired liver function and plasma & platelet leakage s/t dengue fever

Altered health maintenance related to inadequate health seeking behavior

Knowledge deficit related to importance of seeking regular health check-ups

Fatigue R/T physical weakness secondary to Dengue fever

Altered bowel elimination pattern r/t constipation

ANNOTATED
READINGS
SUMMARY

Health Under-Secretary Enrique Domingo said many parents were refusing to get their children vaccinated for polio, chicken pox and tetanus. The fears centre on
Dengvaxia, a drug developed by French company Sanofi. Sanofi and local experts say there is no evidence linking the deaths of 14 children to the drug. However,
the company had warned last year that the vaccine could make the disease worse in some people not infected before. Dengue fever affects more than 400 million
people each year around the world. The mosquito-borne disease is a leading cause of serious illness and death among children in some Asian and Latin American
countries, according to the World Health Organization (WHO). Dengvaxia is the world's first vaccine against dengue. More than 800,000 children were vaccinated
across the country in 2016-17. Fourteen of them have died. Dengvaxia immunisations were halted last year, as the Philippines launched an investigation into what
caused the deaths. Doctors for Public Welfare (DPW) said a clinical review conducted by Philippine General Hospital forensic pathologists had determined that the
deaths were not linked to the vaccine, the Philippine Daily Inquirer reported. In its latest advice on the vaccine, the WHO said that "until a full review has been
conducted, WHO recommends vaccination only in individuals with a documented past dengue infection".

REACTION

Dengue is a disease that our country is facing for many years now and outbreaks happen all year round since we have a tropical climate. Having a vaccine that
could prevent dengue is a good news for us. However, due to the alarming number of people who have died after getting the
vaccine there should really be an investigation done regarding the connection of this deaths to the vaccine. Until there is no
further research done as to why some people have died after getting vaccine I think that it should not be recommended to
reduce the risk of mortality.

REFERENCE:

Philippines gripped by dengue vaccine fears: http://www.bbc.com/news/world-asia-42929

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