Beruflich Dokumente
Kultur Dokumente
INTRODUCTION
A.) OVERVIEW OF THE STUDY
Dengue Fever is found mostly during and shortly after the rainy season in tropical
and subtropical areas like Philippines. Dengue and Dengue Hemorrhagic fever (DHF)
are caused by one of four closely related, but antigenically distinct, virus serotypes
(DEN-1, DEN-2, DEN-3, and DEN-4), of the genus Flavivirus. Dengue is primarily an
urban disease of the tropics, and the viruses that cause it are maintained in a cycle that
involves humans and Aedes Aegypti, a domestic, day-biting mosquito that prefers to
fees on humans. Infection with a dengue virus serotype can produce a spectrum of
clinical illness, ranging from a nonspecific viral syndrome to severe and fatal
hemorrhagic disease. (Gubler, D. and Clark G., National Center for Infectious Disease)
Source: Department of Health Philippines Disease Surveillance Report Morbidity Week 36 ,figure 1 page 1
Sex: Female
Age: 6 years old
Address: Opol, Cagayan de Oro City
Religion: Roman Catholic
Birthday: 07- 16- 2005
Civil Status: child
Nationality: Filipino
Educational Attainment: Preschooler
Date of Admission: June 25, 2012
Time: 5:20 pm
Birthplace: Opol, Cagayan de Oro City
Allergy: No Known Food-Drug Allergy
Height: 112 cm
Weight: 18.5 kg
Mother: Mrs. DR
Occupation: housewife
Income: none
Father: Mr. OR
Occupation: Factory Worker
Income: P5,000-10,000/mo.
Vital signs upon admission:
T: 36.60C
PR: 116 bpm
RR: 17 cpm
BP: 100/70 mmHg
A case of patient J.M.R., 6 years old, child, was admitted at Cagayan de Oro
Medical Center on June 25, 2012 at 5:20 pm with a chief complaint of abdominal pain,
fever and low blood pressure.
4 days prior to admission, onset of fever for 2 days; 2 days prior to admission,
headache. Admitted at Polymedic General Hospital with initial WBC=3500, Hct=36.6,
Platelet count=215,000, initial BP= 90/60 mmhg,HR=120bpm, IVF= D5LR 1L at 60
cc/hr, Right hand consequently with decrease BP of frequent abdominal pain since the
prior day.
Patient started with venolem moderate side drip 200 cc then regulated at 25 cc/hr
fastdrip with Dopamine 2 amp at 22 cc/hr. Transferred ,thus, for ICU admission.
Types of Previous Illness/ Pregnancy/
Date
Delivery
Fever, cough and colds
2012
January, 2012
Heredofamilial disease:
Diabetes
Medication Name
Dose/ Frequency
Paracetamol (Biogesic)
Cefalexin syrup
250 mg q6hrs
2 tbsp. q8hrs
2012
2012
shame in adulthood. The Electra complex is shown by little girls and stems from envy
that they do not have a penis, while their father does. They eventually learn to identify
with their mother. Someone who gets fixated in the phallic stage ends up being overly
vain, reckless and self-assured as an adult.
concepts
necessary
for
everyday
living.
Developing
64 x10^9/L
46 x10^9/L
48 x10^9/L
55 x10^9/L
6
50 x10^9/L
54 x10^9/L
50 x10^9/L
51 x10^9/L
IMPLICATION:
>Low platelet count in dengue fever may result in spontaneous bleeding or may
cause delay in the normal process of clotting. Also signifies patient is positive with the
said illness.
2.) ECG
-RESULT:
Diffuse T wave inversions; saddle-shaped ST-segment elevations (myocarditis)
-IMPLICATION:
Myocarditis refers to an underlying process that causes inflammation and injury
of the heart
Brand
Name
Date
Ordered
Classificati
on
Dose/
Frequenc
y/Route
Merre
m
6-27-12
Antibiotic
750mg
IV
Drip q8
Mechanism
of Action
Inhibits
bacterial
wall
synthesis.
Specific
Indication
Contraindication
Infection of
Hypersensit
ivity.
the
abdomen
ANST(-)
Potassiu
m
Chloride
Kalium
Durule
6-27-12
Potassium
Suppleme
nt
2tabs
q6/
NGT
Side
Effects/
Toxic
Effects
N/V,
Headache,
Diarrhea,
Rash,
Thrombophlebitis
Replace
potassium and
maintain
potassium
level.
Nursing
Precaution
>assess for
any allergy
to
penicillin or
cephalosporins.
>assess for
any brain
disorder.
>assess for
Treatment
of
potassium
Hyperkalem N/V,aria,
severe renal rhythmia,
depletion
impairment;
diarrhea,
symptoms
untreated
Addisons
disease;
severe
tissue
trauma
abdominal
pain, restlessness,
paresthe-
of hypokalemia
>monitor
pulse,blood
sia
pressure
and ECG
signs and
periodically.
Generic
Name of
Ordered
Drug
Tazobacta
m
sodium
Brand
Name
Tazocin
Date
Ordere
d
Classificati
on
6-25-12 antibiotic
Dose/
Frequenc
y/Route
1gm IV
q6
ANST(-)
Mechanism of
Action
Inhibits betalactamase, an
enzyme that
can
destroy
penicillins.
Death of
susceptible organism/
bacteria.
Specific
Indication
Infection
Contraindication
hypersensiti
vity
to
penicillins,
cephalospori
ns,
or
tazobactam
Side Effects/
Toxic Effects
Nursing
Precaution
Diarrhea,
constipation,
nausea,
vomiting,
>assess for
dyspepsia,
specimen
for
culture and
stool
changes,
abdominal
pain,
headache,
insomnia
infection
>obtain
sensitivity
>observe
for
signs and
symptoms
of
anaphylaxis
Generic
Brand
Name of
Name
Famotidine Pepcid
Ordered
Drug
Midazola
Versed
m
Date
Classificati
Dose/
Ordere
on
Frequency
6-25-12 Histamine
18mg
d
/
H2
IVTT
Route
receptor
q12
6-25-12 Sedative/
5mg/5ml
Mechanism
Specific
ContraSide
Nursing
of Action
Indication
indication
Effects/
Precaution
Inhibits the
Prevention
hypersensiti Dizziness,
>note for
Toxic
action
of
vity
headany
Effects
of histamine at ulcer
ache,
epigastric or
Acts at many Used to
Hypersensitiv Headache, >assess level
constipaity,
of
antagonist,
the H2
tion,
abdominal
hypnotic
6 amps
levels of the produce
comatose,
Excess
sedation and
receptor
drowsiness
pain
sedaAnti-ulcer plus
site located
and prank or
(benzodiaz 20cc D5W CNS to
sedation
pregnancy,
tion, agita- level of
prieproduce
marily in
occult blood
pam)
generalized
shock,
tion,
consciousness
gastric
lactation
blurred
parietal cells,
in the stool,
CNS
vision,
throughout.
thereby
emesis or
depression,
inhibiting
short
term
laryngo>monitor
BP,
gastric
acid
gastric
PR
aspirate
sedation
spasm,
and
RR
consecretion.
respiratory tinously.
depression
,
cardiac
arrest.
Dobutami Dobutr 6-25-12 Sympatho- 250
Stimulate
Short-term hypersensitiv Tachycardi >monitor BP,
ne
ex
mg/20ml
beta1
ity
a,
HR,
mimetic
plus 30cc
adrenergic
manageme to bisulfiles;
hpn, preECG,
nt
pulmonary
D5W at
receptors
of heart
Idiopathic hy- mature
capillary
Generic Name
Brand
Date
Classification
Dose/
Mechanism
Specific
Contraindicatio
Side Effects/
Nursing
1cc/
with
wedge
of Ordered
Name
Ordered
of Action failure
Indication pertropic
n
Toxic Effects
Precaution
hr. Frequency/
relatively
ventricular
pressure
Drug
Route
subminor effect
aortic
contractio
10
stenosis
ns,
or heart rate
headache
or peripheral
blood
vessels
Furosemide
Lasix
06-26-12
Loop Diuretic
40mg q8hrs
Inhibits the
Treatment
Hypersensitivity;
Metabolic
>monitor fluid
IVTT
reabsorption
for edema
cross-sensitivity
alkalosis,
status
of sodium &
hypovolemia,
>Monitor BP &
chloride from
sulphonamides
dehydration,
PR before and
the loop of
may exist;
Hyponatremia,
during
Henle &
pregnancy or
Hypokalemia,
administration
distal renal
lactation
hypochloremia,
>asses for
hypomagnesemia
allergy to
tubule
sulphonamides
Norepinephrine
Bitartrate
Levophed
06-25-12
Vasopressor
4mg/4ml 4
Stimulates
Treatment of
Vascular,
Headache;
>monitor BP
drops 84cc
Alpha-
shock
mesenteric or
anxiety,
every 2-3
D5W @
adrenergic
peripheral
dizziness,
mins. Until
1.5cc/hr
receptors
thrombosis;
weakness,
stabilized &
located
pregnancy;
dyspnea,
every 5mins.
mainly in
hypoxia;
decreased urine
There after
blood
hypotension 2 hrs
output,
>ECG should
vessels
to hypovolemia
hypeerglycemia
be monitored
causing
continuously
constriction
>monitor urine
of both
capacitance
physician if it
& resistance
decreases to <
vessels
11
30ml/hr.
Dexamethasone
Nalbuphine
HCL
Dexasone
Nubain
06-30-12
06-25-12
glucocorticoid
4.5mg
Suppresses
Management
Active untreated
Depression,
>monitor
q6hrs IVTT
inflammation
of cerebral
infectious;
euphoria,
and the
edema &
bisulphate,
hypertension,
normal
septic shock
paraben or
nausea,
weight
immune
alcoholic
anorexia,
>assess for
response.
hypersensitivity
decreased wound
changes in
Has
healing, petechia,
LOC
numerous
ecchymosis,
intense
fragility, adrenal
metabolic
suppression,
effects
muscle wasting
Opoids
2mg q12hrs
Alters the
analgesic
IVTT
Hypersensitivity
Sedation,
>assess type,
perception of
to nalbuphine or
headache,
location &
the response
bisulfites ; opiod
dizziness,
intensity of
to painful
dependent
vertigo, nausea,
pain
stimuli, white
patients
vomiting, dry
>assess vital
pproducing
mouth, sweating,
signs before
generalized
clammy feeling
and
CNS
12
For pain
periodically
Depression
Clarithromycin
Phenobarbital
klaricid
solfoton
06-29-12
06-24-12
Antibiotic
anticonvulsants
250/5mg
Inhibits
3ml BID
Infection
Hypersensitivity
Headache,
>monitor vital
protein
to clarithromycin,
diarrhea, nausea,
signs
synthesis
erythromycin, or
abnormal taste,
>Obtain
thereby
other macrolide
dyspepsia,
specimen for
preventing
anti-infectives
leukopenia
culture an
their growth
sensitivity prior
and
to initiating
multiplication
therapy.
30mg/tab 1
Produces all
Febrile
Hypersensitivity
Hangover ,
>monitor
levels of
seizures
comatose
drowsiness, N/V,
respiratory
NGT
CNS
patients or those
constipation,
rate, pulse,
depression;
with pre-existing
lethargy
and BP
inhibits
CNS depression;
frequently
transmission
uncontrolled
>seizure:
in the
severe pain
assess
nervous
location,
system and
duration, and
raises the
characteristics
seizure
of seizure
threshold
activity.
13
V. ANATOMY
ANATOMY AND PHYSIOLOGY OF THE BONE MARROW AND THE SPLEEN
Bone marrow is the flexible tissue found in the interior of bones. In humans, red
blood cells are produced in the heads of long bones, in a process known as
hematopoesis. On average, bone marrow constitutes 4% of the total body mass of
humans; in an adult weighing 65 kilograms (140 lb), bone marrow accounts for
approximately 2.6 kilograms (5.7 lb). The hematopoietic compartment of bone marrow
produces approximately 500 billion blood cells per day, which use the bone marrow
vasculature as a conduit to the body's systemic circulation.Bone marrow is also a key
component of the lymphatic system, producing the lymphocytes that support the body's
immune system.
The two types of bone marrow are medulla ossium rubra (red marrow), which
consists mainly of hematopoietic tissue, and medulla ossium flava (yellow marrow),
which is mainly made up of fat cells. Red blood cells, platelets and most white blood
cells arise in red marrow. Both types of bone marrow contain numerous blood vessels
and capillaries. At birth, all bone marrow is red. With age, more and more of it is
converted to the yellow type; only around half of adult bone marrow is red. Red marrow
is found mainly in the flat bones, such as the pelvis, sternum, cranium, ribs, vertebrae
and scapulae, and in the cancellous ("spongy") material at the epiphyseal ends of long
bones such as the femur and humerus. Yellow marrow is found in the medullary cavity,
the hollow interior of the middle portion of long bones. In cases of severe blood loss, the
body can convert yellow marrow back to red marrow to increase blood cell production.
The spleen is an organ found in virtually all vertebrate animals. Similar in
structure to a large lymph node, the spleen acts primarily as a blood filter. As such, it is
a non-vital organ, with a healthy life possible after removal. The spleen plays important
roles in regard to red blood cells (also referred to as erythrocytes) and the immune
system. In humans, it is located in the left upper quadrant of the abdomen. It removes
old red blood cells and holds a reserve of blood in case of hemorrhagic shock while also
recycling iron. As a part of the mononuclear phagocyte system, it metabolizes
hemoglobin removed from senescent erythrocytes. The globin portion of hemoglobin is
degraded to its constitutive amino acids, and the heme portion is metabolized to
bilirubin, which is subsequently shuttled to the liver for removal. It synthesizes
antibodies in its white pulp and removes antibody-coated bacteria along with antibodycoated blood cells by way of blood and lymph node circulation. The spleen is brownish.
14
A study published in 2009 using mice showed it has been found to contain in its reserve
half of the body's monocytes within the red pulp.
These monocytes, upon moving to injured tissue (such as the heart), turn into
dendritic cells and macrophages while promoting tissue healing. It is one of the centers
of activity of the reticuloendothelial system and can be considered analogous to a large
lymph node, as its absence leads to a predisposition toward certain infections.
CAUSE:
AEDES EGYPTI MOSQUITO
Virus Disseminated
rapidly into the blood
and stimulates WBC
including B lymphocytes
that produce and secrete
antibodies and
monocytes and
neutrophils
15
DENGUE FEVER
DENGUE HEMORRHAGIC
FEVER
Complications
Intense Bleeding
Pulmonary edema
Shock
Hypotension
Nasal
flaring
Shortness
of breath
EENT:
[ ] Impaired Vision [ ] Blind [ ] Pain [ ] Reddened
Productive
[ ] Drainage [ ] Gums [ ] Hard of Hearing
cough
[ ] Deaf [ ] Burning [ ] Edema [ ] Lesion
[ ] Teeth [x] No Problem
[ ] Assess Eyes, Ears Nose, and Throat for Abnormalities.
RESPIRATORY SYSTEM:
[ ] Asymmetric [ ] Tachypnea
[ ] Apnea
[ ] Rales
[x] Cough
[ ] Barrel Chest [ ] Bradypnea
[ ] Shallow
[ ] Rhonchi [x] Sputum
[ ] Diminished
[x] Dyspnea [ ] Orthopnea [ ] Labored
[x] Wheezing
[ ] Pain
[ ] Cyanotic [ ] No Problem
[ ] Assess Resp. Rate, Rhythm, Depth, Pattern,
Breath Sounds and Comfort.
CARDIO VASCULAR:
[ ] Arrhythmia [X] Tachycardia [ ] Numbness
[ ] Diminished Pulses [ ] Edema
[ ] Fatigue [ ] Irregular
[ ] Bradycardia [ ] Murmur [ ] Tingling [ ] Absent Pulses
[ ] Pain [ ] No Problem
[ ] Assess Heart Sounds, Rate, Rhythm, Pulse,
Blood Pressure, Circulation, Fluid Retention, and Comfort.
GASTRO - INTESTINAL TRACT:
[ ] Obese
[ ] Distention [ ] Mass [x] Dysphagia
[ ] Rigidly
[ ] Pain [ ] No Problem
[x] Assess Abdomen, Bowel Habits, Swallowing,
Bowel Sounds and Comfort.
GENITO - URINARY AND GYNE:
[ ] Pain
[ ] Urine Color
[ ] Vaginal Bleeding
[ ] Hematuria [ ] Discharge [ ] Nocturia
[x] No Problem
[x]Assess Urine Frequency, Control, Color,
Odor, Comfort, Gyne-Bleeding and Discharge.
NEURO:
[ ] Paralysis [ ] Stuporus [ ] Unsteady [ ] Seizures
[x] Lethargic [ ] Comatose [ ] Vertigo [ ] Tremors
[ ] Confused [ ] Vision [ ] Grip
[ ] No Problem
[x] Assess Motor Function, Sensation, LOC, Strength,
Grip, Gait, Coordination, Orientation and Speech.
Area: ICU
Weight: 18.5 kgs.
With 02 inhalation
@2LPM via nasal
cannula
With
nasogastric
tube
Dry lips,
ulcer
With ET to MV:
Fi02=30% TV=120
RR=10 PEEp=5
ecchymosis
With
cardiac
monitor
SD#1
Levophed drip
@1.5cc/hr/I.P
Update:
decreased
levophed drip
to 1.4cc/hr
then decrease
SD#2
midazolam
drip (5mg/5ml
midazolam+
30cc D5W) @
0.5cc/hr/IP
Update:
With FBC
attached to
urobag
Levophed drip
(2amps in
17cc D5) @0.4
cc then
decrease by
0.1cc every 4
hours until 0.1
headache
- dry skin
- weakness
- Warm to
touch
- restless
LEGEND:
= FIRST DAY
= SECOND DAY
callus
SUBJECTIVE
COMMUNICATION
Comments: no
[ ] hearing loss
[ ] visual changes verbal cues
[X]denied
OXYGENATION:
[x]dyspnea
[ ]smoking history
none
[x] cough
[x]sputum
[ ]denied
CIRCULATION:
[ ]chest pain
[ ] leg pain
[ ] numbness of
extremities
[X] denied
Comments: no
subjective cues
OBJECTIVE
[ ] glasses
[ ]languages
[ ] contact lens
[ ] hearing aide
R
L
Pupil size: 3mm
[ ] speech difficulties
Reaction: Pupil Equally Round Reactive to
Light and Accommodation
Resp. [ ]regular [x]irregular
Describe: bronchovesicular breath sounds
heard over lungs; RR; 25cpm
R:symmetrical to Left lung upon expansion
L:symmetrical to Right lung upon expansion
Comments: no
subjective cues
NUTRITION:
Diet: 1.100 cal in 1400cc vol. in 6 feedings
(CHO=700, CHON=150, FATS=550)
[]N[]V
Comments: no
Character:
subjective cues
[ ] recent change in
Weight and appetite
[x] swallowing difficulty
[ ]denied
ELIMINATION:
Usual bowel pattern
[ ] urinary frequency
Once a day
3 times a day
[]constipation
[ ]urgency
Remedies:
[ ]dysuria
None
[ ] hematuria
Date of last BM
[ ] incontinence
06-30-12
[ ]polyuria
[ ] diarrhea character
[x] foley in place
None
[ ] denied
MGT. OF HEALTH & ILLNESS:
[ ] alcohol
[x]denied
(Amount, frequency): no subjective cues
[ ] SBE: none
Last Pap smear: none
LMP: none
Full
[ ]
[ ]
[X]none
partial
[ ]
[ ]
Comments: Patient
bowel sounds is
normoactie with 25
bowel sounds
heard upon
auscultation.
with patient
[ ]
[ ]
Bowel sounds:
normoactive
Abdominal Distention
Present [ ] yes [X] No
Urine* (color,
Consistency, odor)
Yellowish, aromatic
*if foley balloon catheter
Is in place none
Briefly, describe the patients ability to follow
treatments (diet, meds, etc.) for chronic
health problems (if present).
N/A
18
SKIN INTEGRITY:
[x] Dry
Comments: no
[ ] Itching
[ ] other
subjective cues
[ ] denied
ACTIVITY/SAFETY:
[ ] convulsion
Comments: no
[ ] dizziness
subjective cues
[ ] limited motion
of joints
[x] ambulate
[x] bathe self
[ ] other
[ ] denied
[X] dry
[ ]cold
[ ] pale
[ ] flushed [X]warm
[ ] moist [ ]cyanotic
*rashes, ulcers, decubitus (describe size,
location, drainage) mouth ulcers noted;
callus noted at both foot
[ ] LOC and Orientation: Patient is conscious
but drowsy.
[ ] Gait [ ] walker [ ] care [] others
[X] steady [ ] unsteady
Sensory and motor losses in face or
extremities: No sensory and motor losses in
face or extremities noted
[ ] ROM limitations: limitation range of
motion to move because of the IV site, ET &
NGT
COMFORT/SLEEP/AWAKE:
[ ] pain
(location) frequency Comments: no
subjective cues
remedies)
[ ] nocturia
[ ] sleep difficulties
[X] denied
COPING:
Occupation: child
Members of household: 5 members
Most supportive person: parents
[ ] facial grimace
[ ] guarding
[ ] other signs of pain: none
[ ] side rail release form signed (60 + years)
N/A
19
breath
Restlessness
Lethargy
Hypoxia
Weakness
NURSING
OBJECTIVE
INTERVENTIONS
DIAGNOSIS
S
Impaired gas At the end of Independent:
1. Monitor vital signs &
exchange
8 hours duty,
cardiac rhythm.
related
to the
patient
2. Evaluate
vital
imbalance
will
capacity by using
ventilation
demonstrate
pulse oximeter to
perfusion
improve
determine
oxygenation.
secondary to ventilation &
3. Elevate head of the
hypovolemic
adequate
bed.
shock.
oxygenation
of tissues.
RATIONALE
EVALUATION
proper
lung
4. Provide
adequate
intake & output.
5. Encourage
position
changes
every
2
hours.
Dependent:
6. Administer Midazolam
5mg/ml 6amps + 20cc
D5W as prescribed.
20
adequate
oxygenation of
tissues.
4. Provide/promote mobilization
of secretions
CUES
Subjective:
No subjective
cues
Objectives:
Bronchial
secretions
Dyspnea
Nasal flaring
Restlessness
Weakness
RR: 25 cpm
Shortness of
breath
Productive
cough
NURSING
OBJECTIVES
INTERVENTIONS
RATIONALE
DIAGNOSIS
Ineffective
airway At the end of 8 Independent:
1. Elevate the head of the
clearance related to hours duty, the
bed above plane.
presence
of patient will be
bronchial
able to maintain
secretions.
airway patency.
2. Suction secretions
needed.
as
4. Ensure
that
the
endotracheal tube to
mechanical ventilator is in
place.
5. Feed per patent NGT
with
strict
aspiration
precaution.
21
EVALUATION
5. To
aspiration,
maintain
patency.
prevent
thus
airway
CUES
Subjective:
No subjective
cues
Objectives:
Dyspnea
Tachypnea RR:
NURSING
OBJECTIVES
INTERVENTIONS
DIAGNOSIS
Ineffective breathing At the end of 8 hours Independent:
1. evaluate cough
pattern
related
to duty, the patient will be
for
the
weak
respiratory able
to
breathe
presence
of
muscles
normally on his own as
secretions
2.
note for any
evidence by negative
pain
or
respiratory distress.
discomfort.
3. Suction airway
as needed.
25 cpm
Use of
accessory
muscle to breath
Nasal flaring
Restlessness
weeakness
4. Elevate
the
head of the bed
30
degrees
above plain.
Dependent:
5. Administere
oxygen
as
ordered by the
physician.
22
RATIONALE
EVALUATION
No subjective cue
Dyspnea
SOB
Restlessness
Lethargy
Hypoxia decreased capillary : 2 seconds
O2 saturation : 93 per cent
imbalance.
Long term: at the end of eight hours nursing interventions,
the patient will be able to maintain adequate ventilation and
adequate oxygenation of tissues.
Short term: at the end of thirty minutes nursing
interventions, the patient will be able to improve ventilation
and adequate oxygenation of tissues.
I
Monitored vital signs and cardiac rhythm.
Evaluated vital capacity by using pulse oximeter to
determine oxygenation.
Elevated head of the bed 30 degrees above plane.
Turned to sides every 2 hours or as needed.
Administered oxygen at 2 liters per minute via nasal
cannula.
E
At the end of thirty minutes nursing interventions, the
patient was able to demonstrate improved ventilation and
adequate oxygenation, thus goal met.
S
No subjective cue
23
Dyspnea
Tachycardia: RR-25cpm
Restlessness
Weakness
Use of accessory muscle to breath
Nasal flaring
P
Long term: at the end of eight hours nursing interventions,
the patient will have normal breathing patterns as evidence
by normal rate and rhythm of respirations.
Short term: at the end of thirty minutes nursing
interventions, the patient will be able to have normal rate
and rhythm of respirations.
I
Evaluated cough for the presence of secretions.
Noted for any pain and discomfort (location,intensity and
severity).
Elevated head of the bed 30 degrees.
Suctioned as needed.
Administered oxygen at 2 liters per minute via nasal
cannula.
E
At the end of eight hours nursing interventions, the patient
was able to maintain normal respiratory patterns, thus goal
met.
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S
No subjective cue
O
Bronchial secretions
Dyspnea
SOB
RR-25cpm
Restlessness
Weakness
Nasal flaring
P
Long term: at the end of eight hours nursing interventions,
the patient will be able to maintain airway patency.
Short term: at the end of thirty minutes nursing
interventions, the patient will be able to maintain airway
patency.
I
Evaluated cough for the presence of secretions.
Noted for any pain and discomfort (location, intensity and
severity).
Elevated head of the bed 30 degrees.
Suctioned as needed.
Ensured that the endotracheal tube is in place.
E
At the end of eight hours nursing interventions, the patient
was able to maintain patent airway, thus goal met.
Second day
S
No subjective cue
25
S
No subjective cue
26
Dyspnea
SOB
Restlessness
Lethargy
Hypoxia decreased capillary : 2 seconds
O2 saturation : 93 per cent
imbalance.
Long term: at the end of eight hours nursing interventions,
the patient will be able to maintain adequate ventilation and
adequate oxygenation of tissues.
Short term: at the end of thirty minutes nursing
interventions, the patient will be able to improve ventilation
and adequate oxygenation of tissues.
I
Monitored vital signs and cardiac rhythm.
Evaluated vital capacity by using pulse oximeter to
determine oxygenation.
Elevated head of the bed 30 degrees above plane.
Turned to sides every 2 hours or as needed.
Administered oxygen at 2 liters per minute via nasal
cannula.
E
At the end of thirty minutes nursing interventions, the
patient was able to demonstrate improved ventilation and
adequate oxygenation, thus goal met.
S
No subjective cue
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Dyspnea
Tachycardia: RR-25cpm
Restlessness
Weakness
Use of accessory muscle to breath
Nasal flaring
P
Long term: at the end of eight hours nursing interventions,
the patient will have normal breathing patterns as evidence
by normal rate and rhythm of respirations.
Short term: at the end of thirty minutes nursing
interventions, the patient will be able to have normal rate
and rhythm of respirations.
I
Evaluated cough for the presence of secretions.
Noted for any pain and discomfort (location,intensity and
severity).
Elevated head of the bed 30 degrees.
Suctioned as needed.
Administered oxygen at 2 liters per minute via nasal
cannula.
E
At the end of eight hours nursing interventions, the patient
was able to maintain normal respiratory patterns, thus goal
met.
EXERCISE
TREATMENT
OUT PATIENT
DIET
and protein.
Instructed and encouraged to eat foods rich in vitamin C
such as oranges.
previous condition and maintain safety. We referred the patient back her current
attending physician if she needs further consultation with regards to her health status.
XII. BIBLIOGRAPHY
1. )http://nursingcrib.com/case-study/dengue-fever-case-study/
2.) http://cmr.asm.org/content/11/3/480.short
3.) http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-relatedto-travel/dengue-fever-and-dengue-hemorrhagic-fever.htm]
4.) Dengue Fever & Dengue Hemorrhagic Fever - Chapter 3 - 2012 Yellow Book Travelers' Health - CDC wwwnc.cdc.gov
5.) http://www.who.int/csr/disease/dengue/en/
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