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Case Study on STAB WOUND


I. PATIENT ASSESSMENT DATA BASE A. GENERAL DATA 1. Patients Name: J.B 2. Address: Tarlac City, Tarlac 3. Age: 23 y/o 4. Sex: Male 5. Birth Date: November 4, 1991 6. Rank in the Family: eldest among four children 7. Nationality: Filipino 8. Civil Status: Single 9. Date of Admission: January 1, 2014 at 3:30 AM 10. Order of Admission: Admit to Surgery ward, Secure consent for admission,Diagnostic test: Complete Blood Count platelet count (CBC), Medications: D5 LRS 1000cc x 30 - 31 gtts/min, . 11. Admitting diagnosis: Dengue Fever Type 2 12. Attending Physician: Dr. Mendoza B. CHIEF COMPLAINT: Patient J.C patient was admitted to surgery with complain of multiple stab wound C. HISTORY OF PRESENT ILLNESS: Prior to admission patient was intoxicated, allegedly stabbed by known/unknown assailant sustaining multiple history/ D. PAST HEALTH HISTORY: According to the patient, he frequently had colds, cough and fever. He never had operations or injuries. Every time he got sick, he would ask medicines from their Health Center this includes Paracetamol. E. FAMILY ASSESSMENT NAME E.B H.B S.L D.L 2 3 RELATION Mother Father

AGE 36y/o 42y/o 13y/o 2y/o

SEX Female Male Female Female

OCCUPATION Housewife Family driver None None

EDUCATIONAL ATTAINMENT High school graduate High school graduate Grade 8 ongoing school None

Child Child

F. SYSTEMS REVIEW - Gordons 11 Functional Health Patterns 1. HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN: Patient perceived health as a very important aspect in life; He stated that,Kailangan natin pangalagaan at panatilihing malusog ang ating pangagatawan para maiwasan ang pagkakaroon ng karamdaman. 2. NUTRITIONAL METABOLIC PATTERN The smell of food stimulates the appetite of the patient; he usually eats vegetables, fish, chicken and meat and drinks 11 glasses of water a day. Appetite: he eats 1 whole of the food served. Usual Daily Menu: Before confinement Usual Daily Menu: During confinement Food: 1 -2 cups of Rice, Fish, Chicken, vegetables - 1 cup of rice. Egg, fish, vegetables - Pinakbet - Dinengdeng - Fried fish Water: 10-11 glasses of water per day - adobo Beverage: pineapple juice Water: 10-11 glasses of water per day Beverage: he drinks soft drinks every other day or occasionally; juice 3. ELIMINATION PATTERN Bowel habits: defecates three times a day before confinement. But during confinement, he only defecate once during our rotation characterized as black tarry formed stool. Bladder: void 5-6 times during our shift. Color: Yellowish color Odor: Pungent 4. ACTIVITY EXERCISE PATTERN: A. Self-Care Ability Before confinement 0- Feeding 0- Toileting 0- Dressing 0- Bathing 0- Bed Mobility 0-Grooming Legend: O - Full self-care II - Requires use of equipment or device III - Requires assistance or supervision from another person

During Confinement 0- Feeding 0- Toileting 0- Dressing 0- Bathing 0- Bed Mobility 0-Grooming

IV - Requires assistance or supervision from another person and equipment or device V - Is dependent and does not participate

5. COGNITIVE PERCEPTUAL PATTERN A. Hearing: there is no hearing impairment, can hear clearly and able to comprehend with instructions when asked.

B. Vision: there is no visual impairment before confinement. C. Sensory Perception: The patient responded when tapped in the shoulder. 6. SLEEP REST PATTERN: Patient state that; He usually sleeps 12midnight and wake up at 6 am before he confined. Now he is in the hospital he sleeps 9pm to 5am. 7. SELF PERCEPTION AND SELF CONCEPT PATTERN: The patient said that he is just simple and kind. 8. ROLE RELATIONSHIP PATTERN: Initially, Patient J.B was able to do responsibilities as a oldest brother such as guiding his siblings by giving a piece of advice when they have a problem. 9. SEXUALLY REPRODUCTIVE PATTERN: Patient was circumcised when he was 11 years old. 10. COPING STRESS TOLERANCE PATTERN: Patient frequently asks questions to minimize his anxiety or consults advise to his parents or siblings whenever he has a problem and base his decisions on it. 11. VALUE BELIEF PATTERN: The patient is Catholic by faith but not an active church-goer. He doesnt believe to any superstitious beliefs.












Stage 6 Older than 12


DEFINITION Significant relations: peer groups and role model Psychosocial virtues: fidelity and loyalty Maladaptations and malignancies: fanaticism repudiation Principled conscience Universal ethical principle orientation, child follows standards of conduct

PATIENT DESCRIPTION Patient states that he can make decisions on his own especially with regards to his education and choosing friends.

The patient knows what is good to what is bad for him and he always obeys his parents whatever they going to say to him.

Male FREUD PUBERTY TO DEATH Genital stage 12-18 years old Sexual pleasure through genitals Behaviors: Becomes independent of parents Responsible for self Develops sexual identity, ability to love and work Reality, abstract thought Can deal with past, present and future Deductive reasoning Able to comprehend and follows instructions when asked, can learn new things easily. Patient is able to maintain genital hygiene and knows what the word sex is.




I. PHYSICAL ASSESSMENT A. General Survey Patient is afebrile, conscious and cooperative. He can ambulate even without assistance and does not appear weak. He wears ordinary clothes such as loose t-shirt and shorts. He is in medium frame. Has slight body odor and doesnt have any deformities. BMI = 22.77 kg/m2 base on the formula weight in kg/( height in meters)2 which is within normal range as shown in the table below.

Category Very severely underweight Severely underweight Underweight Normal (healthy

BMI range kg/m less than 15 from 15.0 to 16.0 from 16.0 to 18.5 from 18.5 to 25

weight) Overweight Obese Class I (Moderately obese) Obese Class II (Severely obese) Obese Class III (Very severely obese) from 25 to 30 from 30 to 35 from 35 to 40

over 40

B. Vital Signs: Temperature: 36.5C Cardiac Rate: 77 bpm Respiration: 32 bpm Blood Pressure: 100/80 mmHg

C. Regional Exam: 1. Skin, Hair and Nails: The clients skin is of normal racial tone which is brown. There were abrasion on the right thigh andthe back of the head . The skin turgor is good and do not have any signs of dehydration. The body hair is evenly distributed while there were portion of hair at the back of the has been shaved due to stab wound.

Hair is black and straight with a barbers cut. No scalp lesions or flaking. Fine hair evenly distributed over arms bilaterally and sparsely on legs bilaterally. There is scarcely hair noted on axilla and on chest, back or face. The clients nail shape is convex clubbing, not well-trimmed and slightly dirty. The nail is smooth and the nail bed is pink. The capillary refill is within 3 seconds and no beaus line noted. 2. Eyes: patient has no complains of blurring of vision or any visul problems; the eye brows are evenly distributed. Eyelids have effectively closure. The Blink response is bilateral, eye balls are symmetrical, bulbar conjunctiva is clear, the palpebral conjunctiva is pink and the sclera is white. The palpebral slant is aligning with the tip of the pinna. The corneal sensitivity reflex is present cornea is transparent, the color of his eyes are brown, the shape are equal, it is uniform in color. Pupils are equal in size. Pupils are equally round and reactive to light and accommodation. He can execute the occular movements. He can recognize objects within 12-14 inches away. The lacrimal apparatus are moist and non-tender. 3. Nose: The color of the clients nose is of racial tone which is brown. His septum is in the midline. The mucosa is pink; nostrils are both patent, nasal flaring is absent. Landmarks are visible. Sinuses are non-tender. 4. Ears: The color of the ear is of normal racial tone which is brown, it is symmetrical. The alignment of the pinna is symmetrical. The pinnas are elastic and recoil when folded. The mastoid process is non-tender. The auditory canal contains some cerumen, the color is brown and there is an absent of discharges. 5. Mouth and throat: The lips is symmetrical and pink, the consistency is smooth, buccal mucosa is pink, the gum is pink, the tongue is in the midline, the color is pink and it is smooth. The tongue movements are not that smooth. The color of the hard and soft palate is pink and is intact. The tonsils are not inflamed. There is presence of mucous. Uvula is in the midline, gag reflex is present. The teeth has a complete set of 32 teeth, with some cavities on the upper and lower molar tooth . 6. Neck and lymph nodes: no pulsations visible, no thyroid enlargement upon palpation and inspection. No tenderness noted. 7. Thorax and lungs: The color of the chest is of normal racial tone which is brown, the shape is AP to lateral ratio 1:2. There are absences of intercostal retraction, costal angle is 45 chest wall are symmetrical, and the chest expansion is symmetrical. Rib slope is less than 90. Respiratory rhythm is regular. The respiratory depth is shallow. Respiratory pattern is normal. When palpated she doesnt feet any tenderness. The vocal fremitus is normal, tactile fremitus is symmetrical. The lung expansion is normal. When percussed the sound is resonance. No adventitious sound heard upon auscultation. Respiratory rate is 32 breaths per minute. 9. Cardiovascular: The rhythm is regular. PMI is located in the apical pulse. Heart rate is 77 beats per minute. 10. Breast and axilla: symmetrical with no signs of dimpling or retraction. Nipples are nearly equal bilaterally in size, no lesions, no abnormal discharges and tenderness. 11. Abdomen: Skin has prominent discolorations of petechial rashes which is pinkish to reddish and white spots, the contour is round. Peristalsis is nonvisible. The color of his stool is black, it is solid and formed. The bowel sound is normo active and no bruits. When percussed the sound is tympany. When palpated he doesnt have any tenderness and when light palpation is done muscle guarding is absent. The liver is not palpable.

12. Extremities: there were present of .The client can resist force when asked to resist. Muscle strength is 5/5. The peripheral pulses are equal. Lymph nodes are not palpable. The IV site is in his left arm. 13. Genitals: Not performed. 14. Rectum and anus: not performed. 15. Neurological/cranial nerves: Olfactory: he is able to differentiate smell from that of an alcohol and perfume. Optic: reacts on both sides. Oculomotor: eyes move smoothly in a coordinated motion in all directions (the six cardinal fields). Trochlear: Bilateral pupils constricts simultaneously when illuminated. Trigeminal: temporal and masseter muscles contract bilaterally when chewing. Abducens: pupils are equally rounded reactive to light and accommodation. Facial nerve: patient is able to smile, frown, wrinkles forehead, shows teeth, puff out cheeks, purses lips, raises eyebrows, and closes eyes against resistance in symetrical movement. Vestibulocochlear: patient is able to hear whispered words from 1-2 feet. Glossopharyngeal: has no difficulty in swallowing. Vagus Nerve: the gag reflex is present. Spinal Accessory nerve: there is symmetric, strong contraction of trapezius muscles when asked to shrug the shoulders against resistance. There is also a strong contraction of sternocleidomastoid muscle on side opposite the turned face when turning the head against resistance. Hypoglossal: can move tongue and can swallow without difficulties.

II.PERSONAL / SOCIAL HISTORY a) Habits/Vices: watching television, eating. b) Caffeine: none. c) Smoking: none. d) Alcohol: none. e) Tea: None. f) Drugs: none g) Lifestyle: none. h) Social Affiliation: not a member of any organization. i) Rank in the family: j) Travel: the patient did not travel within 6 months. nd k) Educational attainment: currently under 2 year high school.

III. ENVIRONMENTAL HISTORY The patient lives in a barangay, near the farm fields and river, but far from their town proper. He lives with his family composed of his father, mother and his 3 sibblings. Their house is concrete and bungalow type. Walking distance from their barangay health center at about 50 meters; they use tricycle or jeepney as their transportation going to their town market and or hospitals.

Water source is from the water district and uses mineral water for drinking. They are using an open-pit privy for their garbages but most of the time, they are throwing their wastes on the riverbank. Used bottles, plastics, and papers are recycled and being sold.


Circulatory System

The circulatory system in humans is a network of blood vessels through which the heart pumps the blood and keeps the blood in circulation. The circulation system provides blood to each cell in the body. The circulatory system comprises of two sub systems cardiovascular system and the lymphatic system. The cardiovascular system consists of the heart, blood and the blood vessels in the form of arteries and veins. The lymphatic system consists of the lymph vessels, lymphatic nodes and lymph. There are two categories of blood vessels arteries and veins. The arteries carry the oxygenated blood from the heart to the rest of the body where it distributes the oxygen and nutrients. The veins carry the deoxygenated blood from the body organs back to the heart. The heart pushes the deoxygenated blood to the lungs, where the blood exchanges the carbon dioxide with fresh oxygen and is returned to the heart for recirculation to the body organs. When the blood reaches the intestines, it collects nutrients for distribution and discards the waste collected from the body cells to the intestines. The blood carries the oxygen and the nutrients to the tissues of the body where it exchanges them with carbon dioxide and waste from the cells. Waste like toxins are released into the kidneys. Another important role of blood is to carry the white blood platelets that have the capacity to fight germs and contain diseases to the infection areas. Therefore, blood helps the immune system of the body.

The Heart The heart is a special involuntary muscle called the cardiac muscle. Involuntary muscles keep working on their own without our intervention or effort. The heart is divided into two sides divided by the septum. Each side has two chambers a ventricle and an atrium. The left side of the heart is responsible for pumping the oxygenated blood from the lungs to the rest of the body. The right side of the heart is responsible for bringing the deoxygenated blood back to the lungs.

The heart keeps beating rhythmically using an electrical signal from the sinoatrial node located at the top of the heart. An electrocardiograph machine can record these electric impulses to study the performance of the heart. The heart is a very important part of the circulatory system. If a part of the blood is lost, one can survive as the blood can get regenerated very quickly. However, any damage to the heart can be fatal. The heart is made up of involuntary cardiac muscles that keep the heart beating without any manual intervention as long as it remains healthy. Blood Vessels The cardiovascular system part of the circulatory system is a closed network of blood vessels through which the blood keeps circulating due to the action of the heart. The blood vessels that carry the oxygenated blood away from the heart to the body organs are called the arteries. The blood vessels that collect the deoxygenated blood and bring it back to the heart are called the veins. The blood vessels are thick near the heart and divide into smaller arteries and finally into capillaries that are only one cell layer thick. Just to compare, the largest arteries called the aorta and the largest vein called the vena cava are each about an inch in diameter! Lymph When the blood carries the nutrition to the individual cells and collects waste, it forms the interstitial fluid between the cells of a tissue to transfer the nutrients to the cells. The lymphatic system is a network of one way vessels that collect the interstitial fluid called lymph into the lymph vessels which push the lymph by rhythmic contractions through several lymph nodes on the way into the subclavian veins where the lymph mixes back with the blood. Blood The blood is composed of fluid called plasma that contains red blood cells, white blood cells and platelets. The plasma carries the proteins, hormones and minerals from one part of the body to the other. The red blood cells contain hemoglobin which helps to transport oxygen from the lungs to the rest of the body parts. The white blood cells help to fight infections and diseases. The blood platelets help to clot after an injury thereby preventing an excess loss of blood.

Blood performs many important functions within the body including: Supply of oxygen to tissues (bound to hemoglobin, which is carried in red cells) Supply of nutrients such as glucose, amino acids, and fatty acids (dissolved in the blood or bound to plasma proteins) Removal of waste such as carbon dioxide, urea, and lactic acid Immunological functions, including circulation of white blood cells, and detection of foreign material by antibodies Coagulation, which is one part of the body's self-repair mechanism Messenger functions, including the transport of hormones and the signaling of tissue damage Regulation of body pH (the normal pH of blood is in the range of 7.35 - 7.45)

Regulation of core body temperature Hydraulic functions

V. INTRODUCTION DENGUE is transmitted by the bite of an aedes mosquito infected with any one of the four dengue virus serotypes. It is a febrile illness that affects infants, young children and adults with symptoms appearing 3-14 days after the infective bite. Dengue is not transmitted directly from person to person and symptoms range from a mild fever, to incapacitating high fever, with severe headache, pain behind the eyes, muscle and joint pain and rash. There is no vaccine or any specific medicine to treat dengue. People who have dengue fever should rest, drink plenty of fluids and reduced the fever using paracetamol or see a doctor.

Dengue is widely distributed in tropical and sub tropical area of the world. In recent years however, it has spread to many countries with outbreaks even in Europe and several countries recording an increasing number of imported cases. Severe Dengue (formerly known as dengue hemorrhagic fever) is characterized by fever, abdominal pain, persisted vomiting, bleeding and breathing difficulty and is potentially little complication, affecting mainly children. Early clinical diagnosis and careful clinical management by trained physicians and nurses increase survival of patient. DISEASE OTHER NAME: CAUSATIVE AGENT DENGUE HEMORRHAGIC FEVER Breakbone Fever, H-fever, Dandy Fever Dengue virus type 1,2,3 and 4 Chikungunya virus Onyong-yong virus Flavi virus Female Aedes aegypti mosquito CHARACTERISTIC: Day Biting Low flying Stagnant Water Urban 3-14 days Mosquito bite GRADE I Fever, headache, joint pain, conjunctivitis, Hermans sign, petechiae, anorexia, abdominal pain, nausea and vomiting GRADE II Grade I + ecchymosis, purpura, epistaxis, melena GRADE III Grade II + shock




GRADE IV Grade III + Profound shock Thrombocytopenia hypovolemic shock



Normal Values



1. 2. 3. 4. 1. 2. 3. 4.

Tourniquet test / Rumple lead test / capillary fragility test Platelet count Viral isolation Serologic test Boric acid / saline compress Codeine, DO NOT GIVE ASPIRIN Calamine lotion BLOOD TRANSFUSION ***Fresh frozen Plasma


VII. RBC 5.4

4.69 6.13 X 10 12/L




5 10 x 10 9/L

Decrease WBC indicates Leukocytosis can be a sign of infection.



0.60 -0.70

Increase Segmenters indicates the presence of an acute bacterial infection or some inflammation going on inside the body



0.20 0.40


Monocyte Hgb Hct

.10 156 0.51

.0 0.07 140 -180 0.40 0.54 150 450 x 10 ^/ L

Increase: indicates presence of infection Normal Normal DECREASED: May indicate decreased platelet production, increased platelet destruction.

Platelets Count



Exam RBC

Result 5.5

Normal Values 4.69 6.13 X 10 12/L

Interpretation Normal



5 10 x 10 9/L

Decrease WBC indicates Leukocytosis can be a sign of infection.

SEPTEMBER 09, 2013



0.60 -0.70


Exam Lymphocytes

Result .43

Normal Values 0.20 0.40

Interpretation Increase Lymphocytes indicates can be sign of infection.

Monocytes Hgb Hct

.12 155 0.43

.0 - .07 140 -180 0.40 0.54

Increase: indicates presence of infection Normal Normal DECREASED: May indicate decreased platelet production, increased platelet destruction.

Platelets Count


150 450 x 10 ^/ L

SEPTEMBER 10, 2013



4.69 6.13 X 10 12/L




5 10 x 10 9/L

Decrease WBC indicates Leukocytosis can be a sign of infection.



0.60 -0.70

Decrease Segmenters indicates the presence of an acute bacterial infection or some inflammation going on inside the body



0.20 0.40

Increase Lymphocytes indicates sign of infection.

Monocytes Hgb Hct

.10 140 0.46

.0 - .07 140 -180 0.40 0.54

Increase: indicates presence of infection Normal Normal Decreased: May indicate decreased platelet production, increased platelet destruction.

Platelets Count


150 450 x 10 ^/ L


GENERIC NAME: paracetamol BRAND NAME: Biogesic CLASSIFICATION: anti-pyretic DOSAGE: 500mg 1 tablet PRN every 4hours for temperature 37.8c and above INDICATION: Fever MECHANISM OF ACTION Drug may relieve fever trough central action in the hypothalamic heatregulating center ADVERSE REACTIONS Leucopenia, nuetropenia, pancytopenia CONTRAINDICATION Contraindicated in patients hypersensitive to drug SIDE EFFECTS drowsiness NURSING CONSIDERATION - Instruct to remain on bed after 30 minutes of giving medication

GENERIC NAME: omeprazole

BRAND NAME: CLASSIFICATION: antiulcer (proton pump inhibitor) DOSAGE: 20mg IVP twice a day INDICATIONS: for pathologic hypersecretory conditions MECHANISM OF ACTION Inhibits proton pump activity by binding to hydrogen-potassium adenosine triphosphatase, located at secretory surface of gastric parietal cells, to suppress gastric acid secretion. ADVERSE REACTIONS Erythema multiforme, pancreatitis, hemolytic anemia, fracture of bone, liver failure, anaphylaxis CONTRAINDICATION Contraindicated in patients hypersensitive to drug or its components SIDE EFFECTS NURSING CONSIDERATION - Promote comfort measures and provide adequate rest periods. - advise to eat frequent small feedings and avoid spicy foods or acidic.

Headache, Fatigue, Dizziness, Light headedness Nausea, vomiting

GENERIC NAME: diphenhydramine

BRAND NAME: CLASSIFICATION: Antihistamine (ethanolamine) DOSAGE: 10mg IVP now INDICATIONS: for allergy symptoms MECHANISM OF ACTION Competes with histamine for H-receptor sites. ADVERSE REACTIONS Seizures, thrombocytopenia, agranulocytosis, anaphylactic shock CONTRAINDICATION Contraindicated in patients hypersensitive to drug. SIDE EFFECTS Drowsiness, Sedation, Sleepiness dizziness NURSING CONSIDERATION - let the patient take a rest and promote comfort. Ensure safety measures. - Assist patient during walking to restroom. Let the patient take a rest.

GENERIC NAME: phytonadione

BRAND NAME: Vitamin K CLASSIFICATIONS: nutritive agent/ anti-coagulant DOSAGE: 10mg IVP now and every 8 hours x 3 doses INDICATIONS: for clotting factor MECHANISM OF ACTION It is a cofactor for a microsomal enzyme that triggers the posttranslational carboxylation of peptide-bound glutamic acid residues into active coagulation factor ADVERSE REACTIONS anaphylaxis CONTRAINDICATION Hypersensitivity to any component of this medication SIDE EFFECTS Skin reaction NURSING CONSIDERATION - Stop the medication immediately then refer to the physician.


FOCUS: abdominal pain ASSESSMENT Subjective: mahapdi yong tyan ko as verbalized Pain scale of 7/10 Objectives: Guarding behavior facial grimace V/S as follows: RR: 32bpm PR: 102bpm Diaphoresis/cold clammy skin pallor DIAGNOSIS Acute pain related to disease process. SCIENTIFIC BACKGROUND Body releases anti inflammatory mediators (cistatin, Kinins) OBJECTIVES After 30 minutes-1 hour of nursing intervention the patients complain of pain will be controlled/ reduced from a pain scale of 7/10 to 3/10 INTERVENTION INDEPENDENT Diagnostics: Assess for referred pain, as appropriate. RATIONALE EVALUATION Goal partially met. Patients complains of pain reduced from pain scale of 7/10 to 4/10.

To help determine for possibility of underlying condition or organ dysfunction requiring treatment. To rule out worsening of underlying condition of development of complication Which are usually altered in acute pain.

Vascular response

Obtain clients assessment of pain to including PQRST of pain

Redness/heat Monitor for vital sign every 4 hours, including skin color and temperature Observe non verbal cues and pain behaviors and other objective, defining the characteristics as noted.

Absominal pain

Observation may not be congruent with verbal reports or maybe only indicator present when client is unable to verbalize

Therapeutics: Provide comfort measures(prepositi oning, quite environment, ventilation) Educative: Encourage adequate rest periods.

To promote non pharmacological pain management

To prevent fatigue.

Instruct and encourage use of relaxation techniques such as DBE Instruct to avoid acidic food

To assist client to explore methods for alleviation or control of pain

This may trigger abdominal pain

DEPENDENT: Administer medication as prescribed: omeprazole 20mg IVP twice a day

Inhibits proton pump activity by binding to hydrogen-potassium adenosine triphosphatase, to suppress gastric acid secretion.

FOCUS: itchy skin ASSESSMENT Subjective: Nangangati ako as verbalized DIAGNOSIS Impaired skin integrity related to presence of petechial rashes. SCIENTIFIC BACKGROUND Cellular direct destruction and infection of red bone marrow precursor cells as well as immunological shortened platelet survival causing platelet lyses OBJECTIVES Short term objective: Within 2hours of nursing intervention, patient will demonstrate behavior in preventing skin impairment INTERVENTION INDEPENDENT Diagnostics: Palpate skin lesions for consistency, texture & hydration. Therapeutics: Provide skin hygiene through sponge bathing & changing regularly Keep bed clothes dry, use nonirritating materials, & keep bed wrinkled free Educative: Encourage reposition schedule for client Provide information to the client about the importance of regular observation & effective skin care RATIONALE EVALUATION Goal met. The patient was able to demonstrate behavior of preventing skin impairment.

Objectives: Redness of the skin Skin rashes all over the body

To assess extent of involvement of skin impairment. To maintain skin integrity at optimal level. To prevent friction that may cause irritation of the skin

Thrombocytope nia

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) of the different organs and skin

To avoid lesions, scratching of skin & harboring of microorganism. To promote wellness by gaining knowledge on treatment/ therapy

Competes with histamine for Hreceptor sites.

Petechial rash

DEPENDENT: Administer medication as prescribed: diphenhydramine 10 mg IVP.

FOCUS: signs of bleeding ASSESSMENT Subjective: maitim yung tae DIAGNOSIS Risk for shock SCIENTIFIC BACKGROUND Dengue virus goes into the OBJECTIVES After 8 hour shift of nursing intervention INTERVENTION INDEPENDENT Diagnostics: RATIONALE EVALUATION Goal partially met. The patient was

ko as verbalized Objective: Decrease platelet count: 57 x 10 g/L Petechial rash all over the body

related to bleeding


patient will report absence of melena.

Monitor for persistent or heavy fluid loss,including vomiting,epistaxis,melena Assess v/s and tissue and organ perfusion including state of consciousness and mentation every 1-4 hours and watch out for any signs of bleeding. Review laboratory data such as CBC and differential count; Platelet numbers; other coagulation factors.

To assess causative/contrib uting factor To note for changes associated with shock stage.

Infects cells and generate cellular response

able to display absence of melena but still had low platelet count.

Initiates destruction of platelets

Increase potential for hemorrhage

To identify potential sources of shock and degree of organ involvement.

Stimulates intense inflammatory response

Educative: Instruct to avoid dark colored foods(for monitoring of melena) and acidic foods.

Dark colored foods may interfere with the result for old blood.

Release of anti inflammatory mediators

DEPENDENT: Administer IVF of D5LRS x 1 liter and regulate to 30-31 gtts/min, as ordered.

Vascular response

To rapidly restore or sustain circulating volume, electrolyte balance, and prevent shock state.

Epistaxis, melena, abdominal pain,

Administer medication as indicated: phytonadione 10mg IVP now and every 8 hours x 3 doses;

It is a cofactor for a microsomal enzyme that triggers the posttranslational carboxylation of


peptide-bound glutamic acid residues into active coagulation factor.


6 days nako nilalagnat bago paconfine, kasi di namin alam na dengue na pala ito, as verbalized. Objectives: Frequently asks questions regarding the disease.

deficit related to lack of information of the Disease.

cognitive information related to lack of information thus development of preventable complications.

objective: After an hour or two of health teaching, the patient will be able to verbalize understanding regarding on his condition, disease process and treatment.

Diagnostics: Ascertain level of knowledge, including anticipatory needs. Determine clients ability, readiness, and barriers to learning.

To assess readiness to learn. Individually may not be physically, emotionally or mentally capable at this time. To provide information and prevent overload. To answer questions and validate information. So that client feels competent and respected.

patient was able to verbalize understanding regarding on his condition, the disease process and treatment.

Therapeutics: Provide information relevant only to the problem. Provide access information.

Educative: Discuss clients perception of need. Relate information to clients personal desires, needs, values and beliefs. Explain the disease process ( signs and symptoms ), identify possible causes. Describe the condition of the client

Increase knowledge and reduce anxiety


Subjective: Nakaka stress na dito sa ospital, as verbalized

Anxiety related to stress to hospitalization .

Objectives: Worries about hospitalization Increase RR 32bpm Increase tension Restlessness

BACKGROUND Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.

Short term objective: After 2 hours of nursing intervention the patient will be able to verbalized reduce feeling of anxiety

INDEPENDENT Diagnostics: Help the client to determine the source of anxiety. Help the client to determine the level of anxiety.

These actions will help the client to establish realistic understanding of the nature and cause of anxiety. Once stress is accurately understood and the client can readily identify strategies for coping.

Goal met. The patient was able to verbalized reduced feeling of anxiety

Therapeutics: Provide support, stay with the client speak slowly and calm and convey a sense of caring and empathy. Educative: Encourage client to verbalize feeling and express emotions.

Providing reassuring presence decreases the client stress of alones and support the clients coping.

Sharing concerns and expressing emotions can decrease the clients feeling being alone or overwhelmed by stressful situation.

X. LIST OF IDENTIFIED PROBLEMS Acute pain related to disease process. Risk for impaired skin integrity related to presence of petechial rashes.

Risk for shock related to bleeding. Knowledge deficit related to lack of information Anxiety related to stress to hospitalization Disturbed body image related to presence of rashes all over the body Risk for imbalanced Nutrition Less Than Body Requirements related to inadequate nutritional intake due to decreased appetite

XI. ONGOING APPRAISAL September 10, 2013 > Received lying on bed with an ongoing IVF of D5LRS 1li at 650 cc level regulated at 30-31 gtts/min infused at the left arm. Conscious and coherent, afebrile and can do Activities of daily living without assistance. TPR every 4 hours and recorded. All due medications are given. September 11, 2013 > Received sitting on chair with an ongoing IVF of D5LRS 1 li at 200cc level, infusing well at the left arm. Conscious and coherent, afebrile and can move without assistance. Still under monitoring. TPR every 4 hours and recorded. Due medications are given. Endorsed for continuity of care.

XII. DISCHARGE PLAN (HEALTH TEACHING) Diet: > Encourage nutritious foods like vegetables, meat and fruits. Medications: > Give paracetamol in case the temperatures increases and avoid giving aspirin when dengue fever is suspected. Outpatient follow-up > Follow-up check-up after 1 week with the doctor to identify and prevent reoccurrence of signs and symptoms of dengue Treatment: > Increased oral fluid intake. Health Teaching: > D- discuss the possible source of infection of the disease. > E- educate the family/patient on how to eliminate those vectors. > N- Never stocked water in a container without cover. > G- Gallon, container and tires must have proper way of disposal. > U- Use insecticides to kill or reduce the population of mosquito at home. > E- Encourage the family of the patient to clean the surroundings to destroy the breeding places of mosquito. The best way to prevent dengue fever is to take special precautions to avoid contact with mosquitoes. Eliminate vector by:

Changing water and scrubbing sides of lower vases once a week Destroy breeding places of mosquito by cleaning surroundings Proper disposal of rubber tires, empty bottles and cans Keep water containers covered

Because Aedes mosquitoes usually bite during the day, be sure to use precautions especially during early morning hours before daybreak and in the late afternoon before dark. Other precautions include: When outdoors in an area where dengue fever has been found Use a mosquito repellant containing DEET, picaridin, or oil of lemon eucalyptus Dress in protective clothing-long-sleeved shirts, long pants, socks, and shoes Keeping unscreened windows and doors closed Keeping window and door screens repaired Use of mosquito nets