STI COLLEGE OF NURSING

Eagle St. San Isidro Village, Kauswagan

Cagayan de Oro City

Viral Myocarditis Secondary to Dengue Fever

In Partial Fulfillment in the Requirements of

NCM 102E-RLE

Submitted by:

Group 2

Baslao, Aiza G.
Gamalo, Isa C.
Indoy, Sunshine Hope P.
Lagamon. Alyssa Ruby U.
Lobetaña, Jeffrey B.
Maglangit, Hannylene S.
Pioquinto, Rodeline P.
Rivas, Wiludia E.
Sabado, Kennith L.
Salinas, Carmela S.
Selibio, Rickmon T.
 TABLE OF CONTENTS

Page Content Page Number

I. INTRODUCTION 1- 2
II. OBJECTIVES OF THE STUDY 3
III. SCOPE AND LIMITATION OF THE STUDY 4
IV. PATIENT'S PROFILE 5
V. DEVELOPMENTAL DATA 6
VI. PAST & PRESENT HISTORY OF PRESENT ILLNESS 7
VII. ASSESSMENT 8 – 10
VIII. ANATOMY AND PHYSIOLOGY 11 – 12
IX. PATHOPHYSIOLOGY 13 – 14
X. MEDICAL MANAGEMENT
a. Laboratory Results 15 – 17
b. Doctor's Order 18 – 21
c. Drug Study 22 – 25
XI. NURSING CARE PLAN
a. Ideal Nursing Care Plan 26 – 28
b. Actual Nursing Care Plan 29 – 31
XII. DISCHARGE PLAN 32 – 33
X. PROGNOSIS 34
XI. REFERENCE 35
 I. INTRODUCTION

This is a case of Ms. X, seven years of age, female, residing at

Sugbongcogon, Tagoloan, Misamis Oriental. She is diagnosed with viral myocarditis
secondary to dengue fever.
Being assigned in the pediatric ward at Maria Reyna Hospital, we chose this
case because we find it interesting, due to the fact that there are only few cases
reported about viral myocarditis, caused by a dengue virus. This case would give us
further knowledge and information why a certain individual acquires this disease.
Viral myocarditis is an inflammatory disorder of the myocardium with necrosis
of the myocytes and associated inflammatory infiltrate. It is usually caused by a viral
infection, but there are only limited data available with respect to dengue virus
involvement. However, occurrence of myocarditis can be affected by viral epidemics
like dengue.
Although myocarditis is severe enough to be recognized as rare, it is the most
common cause of heart failure in otherwise healthy children. In both children and
adults, most cases are subclinical; thus, the true incidence of myocarditis in children
is unknown. When diagnosis is suspected and severe cardiovasvular compromise
follows, it requires admission to Pediatric Intensive Care Unit (PICU).
Unfortunately, the clinical features of myocarditis can vary widely, and often
no cardiac signs or symptoms occur, complicating its recognition. Its clinical
manifestations widely vary in mild forms to few or no symptoms are noted. In severe
cases, patient may present with acute cardiac decomposition and may progress to
death. Initial symptoms include the following: irritability, lethargy, periodic episodes of
pallor, fever, hypothermia, tachypnea, anorexia, wheezing and diaphoresis with
feeding. In severe cases, low cardiac output may progress to acidosis and death.
End organ damage may develop because of direct viral infestation or because of low
cardiac output. Central Nervous system involvement may also develop. Older
children present with similar symptoms and may experience lack of energy and
general malaise. In addition, there is also nonspecific flulike illness, gastrointestinal
symptoms, poor feeding or rapid breathing. Sign of diminished cardiac output, such

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as tachycardia, weak pulse, cool extremities, decreased capillary refill, and pale or
mottled skin maybe present. Heart sounds may be muffled, especially, in the
presence of pericarditis. An S3 may be present and heart murmurs, caused by
atrioventricular valve regurgitation, may be heard. Hepatomegaly may be present in
younger children. Rales may be heard in old children. Jugular venous distention and
edema of the lower extrimities maybe present. In the acute phase of viral
myocarditis, the patient should be admitted to the hospital, even if only mild signs of
respiratory distress or congestive heart failure are present, because this will lead to
rapid progression of over heart failure and hemodynamic collapse, or both may
occur.
Medical care is aimed at minimizing hemodynamic demands of the body. No
specific proven therapy is available to prevent the myocardial damage, but
maintenance of tissue perfusion is the goal to avoid further complications. Normal
arterial blood oxygen levels should be maintained with supplemental oxygen as
needed. Surgery is done when the extent of damage cause severe malfunction. A
low salt diet is recommended for patient with congestive heart failure. Bed rest is
necessary during the acute phase of the illness which may slow the intramyocardial
replication of the virus. Activity is permitted as partial or complete recovery is
achieved. Immunosuppressive agents are also used to reduce inflammatory process
inhibiting T cell activity. Inotropic agents are used when cardiac output cannot be
maintained by less invasive measures. Dopamine, dobutamine are the most
commonly used vasopressors. New therapeutic agents are being studied as
candidates for the treatments of myocarditis. These include agents that inhibit the
virus entrance to the cell, antiviral agents that inhibits translations, transcriptions, or
both, and interferon, among others.

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II. OBJECTIVES OF THE STUDY

With the case study presentation, we intend to:

1. Identify the anatomy and physiology of the cardiovascular system particularly

the heart's myocardium.

2. Discuss the causes of dysfunction of the aforementioned bodily systems.

3. Explain and connect the assessment of the client to the clinical manifestations
of the condition and its pathophysiologic process.

4. Determine the medical and nursing management of the patient with the said
disease and its complications.

5. Create a nursing process approach to serve as a background or blueprint of

care for the client.

6. Identify the prognosis of a client affected with viral myocarditis.

7. Identify lifestyle revision for health maintenance in the discharge plan.

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 III. SCOPE AND LIMITATION OF THE STUDY

This study deals with the general knowledge of viral myocarditis including its
ideal management and prevention. It also aspires to deal with the pathophysiological
features of the disease and covers the anatomy and physiology of the
cardiovascular system particularly the hearts myocardium triggered by the
abnormalities and complications, causing the said condition.

It consists of nursing care plans integrated to serve as a framework of care for

the client with the support of the diagnostic evaluation and assessment findings.
Furthermore, the study focuses on determining and assessing on how the said
condition is acquired and to avoid developing such possible complications. Our
study is limited due to the fact that the scope focuses only on the possible
management of viral myocarditis in the given span of life. Since we only had a one
(1) day exposure to the patient, we only had limited time to acquaint ourselves with
the client regarding her needs and other factors related to her condition thus, we
only render our nursing care plans with only short sighted management and
interventions.

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IV. PATIENT'S PROFILE

Patient’s Name: Ms. X

Address: Zone 5, Sugbongcogon, Tagoloan, Misamis Oriental
Age: 7 years old
Sex: Female
Birth Date: April 15, 2002
Birth Place: Bugo, Cagayan de Oro City
Religion: Roman Catholic
Nationality: Filipino
Father’s Name: Father X
Mother’s Name: Mother X

Admission Date: February 19, 2010

Time of Admission: 5:47 PM
Chief Complaint: weakness, fever
Diagnosis: Viral myocarditis secondary to dengue fever
Physician: Anne B. Agnes, M.D.

RR: 55 cpm
T: 39.2 ºC
PR: 115 bpm
BP: 50/40 mmHg
Allergies: No known food and drug allergies

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 V. DEVELOPMENTAL STAGE

Sigmund Freud introduced a member of concepts about development that

are used today. The concepts on unconscious minds, defense mechanism, ego and
superego are Freud's theory. The personality develops in five overlapping stages –
from birth to adulthood.
According to Freud's theory of psychosexual patient, a school-age child
belongs to the “latent phase”, where our patient belongs too. This is the time that
her personality development appears to be non-active or dormant. Her libido
appears to be diverted into concrete thinking in which energy is directed to physical
and intellectual activities. The sexual impulses tend to be repressed at this time so
she developed relationship between peers of the same sex.
The central task at of school-age is “industry vs. inferiority”. During this
period, she learned the concept of initiativity - the ability to do things necessarily by
oneself. She learns to create, develop and manipulate things on her own way.
Children at this age, when encouraged in their efforts, their sense of industry grows.
On the case of our patient, she does not make her effort in doing her schoolwork
because she is affected by the separation of her parents, losing her sense of
industry.
In accordance to Piaget's theory wherein our patient is in the school-age
period, she belongs to the “concrete operational phase”. She was able to discover
concrete solutions to everyday problems and recognize cause and effect
relationships. She thinks that if she would become very ill to look at, then her parents
would probably visit her and sooner they will be together as a whole family again.

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 VI. HISTORY OF PAST AND PRESENT ILLNESS

a. Past History of Illness

According to the grandmother, about three (3) years ago, the patient was
admitted for the first time at J.R. Borja General Hospital. Three (3) days prior to
admission, the patient had remittent fever, general weakness and presence of
edema in the extremities. This prompted the grandmother to admit the patient and
was diagnosed of DHF (dengue hemorrhagic fever). After one (1) week of
admission, the patient was able to recover and was discharged.

b. History of Present Illness

Last February 17, 2010, the patient was admitted for the second time around
at Maria Reyna Hospital (MRH). According to the grandmother, the patient had fever
for two (2) days prior to that admission. Within that day, the patient recovered and
was discharged.
However, the day after, the patient complained of sudden general weakness,
malaise. The next day, the grandmother together with the patient went to Diesto
Clinic for a check-up. Upon assessment by the doctor, the patient fainted suddenly
and her blood pressure and pulse rate goes undetected. The patient was then
immediately referred to and re-admitted to MRH as an emergency case.

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 VII. ASSESSMENT

CLIENT PROFILE
Name: Patient X Age: 7 years old
Birthday: April 15, 2002 Birthplace: Bugo, CDO City
Address: Zone 5 Sugbongcogon, Tagoloan, Misamis Oriental
Religion: Roman Catholic Current Education Level: Grade 1
Name of School: Gracia Elementary School
Name of Parents/Guardian: Mr. & Mrs. X
Name of Informant: Mrs. X Relation to Client: Grandmother
Attending Physician: Anne B. Agnes, M.D
Date of Admission: Feb. 19, 2010 Room/Ward#: HCA 9 # of Days Admitted: 6 days
Chief Complaints/s upon Admission: weakness
Medical Diagnostic, if any: Viral Myocarditis Secondary To Dengue Fever
Current Medications:
Name of Drug/s Dosage Indication
dobutamine hcL 20ml (280mg/20ml) Increases heart contractility
(Dobutrex) IVTT
famotidine 2omg IVTT q 12 hr Intractable ulcerations or hyper
(Pepcid) secretory conditions
terbutaline sulfate 5ml PO TID Prophylaxis for bronchospasm
(Bricanyl)
dopamine hcL 1amp + 200cc D5W Correction of hemodynamic
(Revimine) via syringe pump imbalances present in the shock
syndrome

Past Hospitalization, if any: 2006- JRB hospital (dengue ), Feb. 17- 18, 2010- Maria
Reyna Hospital (fever )
Past Treatments, if any: (2004 ) asthma (maintenance for five months ), (2004 )
convulsion, (2006 ) DHF
I. HEALTH PERCEPTION - HEALTH MANAGEMENT PATTERN

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Appearance: weak, restless, confuse, irritable, w/ diaphoresis, pale & dusky skin
color as noted
Grooming: not well groomed since the client was not well combed, untidy and dirty
nails
Posture: lying on bed
Height: 131 cm
P.R: 115 bpm, presence of heart murmur R.R: 55 cpm Temperature: 39.2ºC
B.P.: 50/40 mmHg
Immunization received including date:
BCG- I dose Hepatitis B- III doses
DPT- III doses Measles- I dose
OPV- III doses

II. NUTRITIONAL METABOLIC PATTERN

Skin Color: pale and dusky Texture: cold clammy skin and poor skin turgor
Lesions: N/A Texture: N/A
Hair Color: black Texture: fine
Lesions: N/A
Nail Color: pale Condition: slow CRT (3- 4 secs ), dirty and long nails
Oral Mucosa: Teeth: incomplete teeth with tooth cavities Condition: pallor
Daily Food Intake:
Breakfast: 1 cup rice, 1 cup soup, hotdog; consumed meal half share with fair
appetite
Lunch: 1 cup of rice, 1 fried chicken; consumed with fair appetite
Dinner: 1 cup of rice. ½ cup soup, hotdog; consumed with fair appetite
Snacks: 2 pcs. of bread, juice and fruits like lanzones and orange
Food Supplements: N/A
Vitamins taken: Vitamin B complex, Ascorbic Acid (Ceelin )

II. ELIMINATION PATTERN

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Bowel Habits:
Frequency: once a day Color: brown stool
Consistency: soft and formed stools Amount: adequate amount
Bladder Habits:
Frequency: 3 times a day Color: yellow
Amount: 200cc

IV. ACTIVITY – EXERCISE PATTERN

Daily Activities: sleeping, writing, playing with her cousins
Leisure Activities: watching fairy movies, listening to music, drawing
Exercise Routine: walking, standing

V. SLEEP – REST PATTERN

Time of Sleep: 9pm- 6 am, nap 1 pm- 3 pm Quality: deep sleep
Sleep aid/s: listening to music

VI. SENSORY – PERCEPTUAL PATTERN

Vision: able to initiate eye to eye contact Aid/s for Vision: N/A
Hearing: turns to the source of sound Aid/s for Hearing: N/A
Smell: good

VII. COGNITIVE PATTERN

Ability to express:
Able to verbalize feelings, desires & emotions. She smiles and laughs when she’s
happy & shows negative behaviors when wants are not met; she has labile moods.

VIII. ROLE – RELATIONSHIP PATTERN

Ordinal Position of Client in the Family: first and only child
Primary caregiver of Client: grandmother
Other support system of client: parents, relatives
VIII. ANATOMY AND PHYSIOLOGY

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 The heart structures of the cardiovascular system, the blood and the blood
vessels, play a vital role in human physiology. The major function of the
cardiovascular system is transportation. Using blood as the transport vehicle, the
system carries nutrients, gases, waste, antibodies, electrolytes, and many other
substances to and from body cells. Its propulsive force is the contracting heart.
The heart is a cone-shaped muscular organ located within the thoracis. Its
apex rest on the diaphragm, and its base is at the level of the fifth rib. The coronary
arteries that nourish the myocardium arise from the aorta. The coronary sinus
empties into the right atrium. Relative to the roles of the heart chamber, the atria are
the receiving chambers, whereas the ventricles are discharging chambers. Both
chambers have right and left parts divided by a septum. The membrane that lines
the heart and also forms the valve flaps is called the endocardium. The outermost
layer of the heart is called the pericardium. The fluid that fills the pericardial sac acts
to decrease friction during heart activity. The heart muscle, or myocardium, is
composed of a specialized type of muscle tissue called the cardiac muscle. These
heart muscles contract due to the heart’s specialized conducting system – the SA
(sinoatrial) node. Although the heart can contract independently, it is still somehow
controlled by the autonomic nervous system to increase or decrease heart
contraction to increase and/or decrease cardiac output depending on a situation.

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 Blood, the vital fluid that courses through the body's blood vessels, provides
the means by which the bodies cells receives vital nutrients and oxygen and dispose
of their metabolic waste. As blood flows past the tissue cells, exchanges continually
occur between the blood and the tissue cells, so that vital activities can go on
continuously.
Formed elements, the living blood cells that make up about 45% of whole
blood includes (1) erythrocytes or RBCs – disk-shaped, anucleate cells that
transport oxygen bound to their hemoglobin molecules, (2) leukocyte or WBCs –
ameboid cells involved in protection of the body, and (3) platelets – cells fragments
that act in blood clotting.
White blood cells (WBCs) are important in fighting off infections in the body.
They are an important part of the immune system. They are classified into major
groups based on the presence of granules: granulocytes and agranulocytes.
Granulocytes include neutrophils, eosinophils and basophils. Agranulocytes on the
other hand includes lymphocytes and monocytes. White blood cells are only
activated by chemical messengers in the body such as chemicals produced by the
inflammatory process.
Neutrophils are involved in acute infections and are the first macrophage
present on an infection site. They are also the one that comprises most of the white
blood cells. When infection is caused by a virulent pathogen and/or a virus, they
decrease in number because of their inability to fight off the infection. Eosinophils,
on the other hand, are involved in parasitic infections while basophils fights off
allergens that is responsible for the development of allergies.
Lymphocytes and monocytes are part of the specific immune system which
is the last line of defense against invading pathogens. Monocytes are the second
kind of macrophage. Lymphocytes are classified into T lymphocyte and B
lymphocyte. T cells and B cells work hand in hand to fight off those pathogens that
have escaped from the first two defenses. (the first is the mechanical barrier
comprises of the skin an mucous membrane and the second is the chemical barrier
that involves the inflammatory response.)

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X. MEDICAL MANAGEMENT
a. Laboratory Results

HEMATOLOGY REPORT

O2/20/10 RESULT REFERENCE REMARKS

CBC
Total WBC 3.8 5.0-15.0 Abnormal – presence of viral infection
Total RBC 5.45 3.69-5.90 Normal
Hemoglobin 15.4 11.70-14.0 Abnormal - low oxygen level
Hematocrit 43.8 34.10-44.0 Normal
MCV 80.4 70.0-97.0 Normal
MCH 28.3 26.10-33.30 Normal
MCHC 35.2 32.0-35.0 abnormal-low oxygen level
Platelet count 240 150.0-390.0 Normal

Differetial
Count 20.0 37.0-72.0 abnormal- presence of infection
Neutrophils 61.3 20.0-50.0 abnormal- presence of infection
Lymphocytes 16.6 8.0-14.0 abnormal- presence of infection
Monocytes 1.3 0.0-6.0 Normal
Eosinophils 0.0 0.0-1.0 Normal
Basophils
12.5 11.50-14.50 Normal
RDM-CV

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 URINALYSIS
Date: 02/20/10
Color Light Yellow Interpretation
Transparency Clear
Specific Gravity 1.005
pH 7.5
Sugar Negative
Protein Negative
MICROSCOPIC
FINDINGS: -
RBC 0-1/hpf The urinalysis results are
Pus Cells Rare within normal reference
Epithilial cells - indicating that urinary
mucus threads - functions are also normal.
Renal Cells -
Yeast Cells Few
Bacteria
CRYSTALS:
Amorphous Urates/PO4 -
Calcium Oxalates -
Uric Acids -
Triple PO4 -

CAST:
Coarse Granular -
Fine Granular -
Pus Cast -
Waxy Cast -
RBC -

OTHERS -

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 ECG FINDINGS
02/20/10

Rhythm: Sinus Axis: 75 bpm

Rate: Arterial: 68-83 bpm Ventricular: 68-83 bpm
P.R: 0.12 sec. Q.R.S: 0.08 sec. Q.T: 0.34 sec.
.
ECG DIAGNOSIS:
Sinus Arrythmia

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XI. DISCHARGE PLAN

 Instruct patient’s primary caregiver to follow and

continue the intake of vitamin B-complex by the
MEDICATION patient as prescribed by the doctor:
- Appebon Syrup OD 2 tsp after breakfast

 Instruct patient's primary caregiver to provide

clean and peaceful environment.
 Inform patient's primary caregiver to always
empty all the stock bottles in their house to
ENVIRONMENT eliminate possible breeding grounds of the
mosquitoes.
 Educate patient's family about the importance
of the proper ways of cleaning the surroundings.

 Instruct patient's primary caregiver to provide

adequate bed rest to minimize the workload of the
patient's heart.
 Inform patient's primary caregiver to provide
TREATMENT
patient low-salt diet.
 Avoid all strenuous activity that can make the
patient tired.

 Instruct primary caregiver to prepare foods that

are appetizing and nutritious.
 Educate primary caregiver to give emphasis on
the importance of proper hygiene.
HEALTH TEACHINGS
 Recommend to patient’s primary caregiver to
make the patient wear long comfortable sleeves
and long socks to protect against mosquito bites
or to apply mosquito repellants.

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  Inform primary caregiver to notify the physician
if symptoms set in.
OUT-PATIENT  Inform primary caregiver to have a medical
check-up once a week to monitor the heart’s
activity.
 Inform the patient's primary caregiver that give
child food that is low in salt.
DIET  Inform the primary caregiver to give the child
nutritious food and provide iron supplement
vitamins.
 Instruct patient's family to continue to believe in
SPIRITUALITY GOD and always have faith with HIM.

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X.PROGNOSIS

The prognosis of the patient with Viral Myocarditis secondary to Dengue fever
depends on the access of medical care, financial resources, and successful
implementation of preventive measures and controlled transition of the disease.
Since the patient is financially supported by her family and relatives, she can
really afford in complying all the medications prescribed by her physician. Aside from
that, she was discharged in good condition. Therefore, we conclude that the patient’s
prognosis is good.

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XIII.REFERENCES

BOOKS
• Berman, Snyder, Kozeir, Erb (2008). Fundamentals of Nursing(8th edition)
• Amy M. Karch(2008). Focus on Nursing Pharmacology(4th edition)
• Adele Pititteri(2003).Maternal & Child Health Nursing
• Amy M. Karch(2010).Lippincotts Nursing Drug Guide(4th edition)
• Elaine N. Marieb(2006). Essentials of Human Anatomy & Physiology(8th
edition)
• Marilynn E. Doenges, Mary Frances Moorhoose, Alice C. Murr (2006),
Nursing Care Plan(7th edition)
• Marilynn E. Doenges, Mary Frances Moorhoose, Alice C. Murr (2002),
Nurse's Pocket Guide(8th edition)

INTERNET
o http://ccn.aacnjournals.org/cgi/content/full/28/1/42#SEC6
o http://emedicine.medscape.com/article/890740-overview
o http://www.virtualmedicalcentre.com/anatomy.asp?sid=16#C8
o http://usasam.amedd.army.mil/_fm_course/Study/UnderstandingECG.pdf
o http://en.wikipedia.org/wiki/Blood
o http://en.wikipedia.org/wiki/Immune_system
o httpmerckandcoinc.net/mmpe/sec06/ch067/ch067c.html
o http://www.scribd.com
o http://www.google.com
o http://www.ask.com

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