DENGUE FEVER

A Case Analysis presented to the staff educators of the Continuing

Education Center

Asian Hospital And Medical Center

In partial fulfillment of the requirements in perceptorship Journey for the

Basic Competency program

Princess Lobetania Viluan RM, RN

Thursday, August 29, 2019

 Table of Contents

I. Title page
II. Overview of anatomy and physiology
III. Database

a.) Patient profile

b.) Chief complaint
c.) Admitting diagnosis
d.) History of past present illness
e.) Past medical history
f.) Family history
g.) Review of systems
h.) Course in the Ward/ Area
i.) Physical assessment findings

IV. Laboratory and Diagnostics procedures

V. Medications
VI. Theoretical framework
II. Overview of the Anatomy and Physiology
III. Database

a.) Patient profile:

Patient’s name: D.J.S.
Birthdate: 20- October- 2010
Race: asian
Age: 9 yrs. Old
Gender: male
Weight: 29.2 kg
Ht:
Religion: Christian
Nationality: Filipino
Address: 86 Freixas St. BFHEVA, BF homes Paranaque City
Attending Physician: Dr. P.H
Admitting Diagnosis: Dengue Fever
Name of the Informant: D.J.S
Admission Date: August- 21-2019 2050H

b.) Chief Complain: Fever

c.) Admitting Diagnosis: Dengue fever

d.) History of present illness: Patient came in to ED due to fever for 4

days. Onset of fever was Sunday, August 18 2019. Patient also
complained of mild headache, cough and loss of appetite.

e.) Past Medical History: patient is known to have asthma for the past 2
years. Patient has no known allergies in foods and medicines.

f.) Family History: Patient’s father is known asthmatic other than that,
there are no more illness in the family.

g.) Review of Systems

 SIGNIFICANT EVENTS

Skin Dry and warm to touch

Skeletal unremarkable
Cardiovascular Hear rate of : 99bpm = normal
Head Mild Headache
Eyes unremarkable
Ears No discharge, no signs or history
of infections
Mouth, Teeth and tongue No signs of swelling or bleeding
noted.

Hematologic Non anemic, with Low White

Blood Cell count (2.5) and Low
Platelet count ( 174)
Gastrointestinal Loss of appetite, patient did not
vomit from the onset of fever up
to admission date.

h.) Course In the Ward

Date and Time Significant Events Nursing

Intervention
08-21-2019/ 2050H CBC with platelet Results
count and Dengue posted at
Panel 2153H
Fever (38’c) Paracetamol
250/5ml given
every 4 hours
IVF D5.03 NSS 500ml Started IVF at
to run for 80ml/hr 2215 LMCV
G24

08-22-2019 IVF to follow: D5 0.3 Hooked IVF at

0230H nacl I liter at 80ml/hr 0400H
 Medtech
Repeat CBC with informed
platelet in AM
Paracetamol
Fever (38.2’C) given at
2220H

Physical Assessment Findings

Technique Findings
General Appearance Patient appeared to be
weak
Skin Skin is warm to touch, No
rashes, edema or bleeding
noted
Abdomen No abdominal tenderness
noted. Uniform in color,
intact and soft.
Neurologic Patient is alert with no pain,
GCS 15
Eye- 4
Verbal- 5
Motor- 6

IV. Laboratory and Diagnostic Procedures

CBC
Test Result Unit Reference Interpretation
range
WBC 2.5 X10^9/L 4.5-13.5 Low: Viral
Infection is
present
RBC 4.59 X10^2/L 4.00-5.20 Normal: no
presence of
bleeding.
 Hemoglobin 136 g/L 120-150 Normal: no
presence of
bleeding.
Hematocrit 0.40 L/L 0.33-0.43 Normal: no
presence of
bleeding.
Platelet count 174 x 10^9/L 150-400 Normal
lymphocytes 47 % 29-49 Normal
Monocytes 11 % 2-9 High:

Immunology- IH

Dengue Panel- Full

Test Result
Dengue NS1 Positive
Dengue IG Negative
Dengue Igm Negative

V. Medications

Date Medication Indication Pertinent Correlation with

Ordered Nursing the patient’s
Consideration condition
08-21- IVF D5.03 Used to Monitor input To treat
2019/ NSS 500ml treat water and output patient’s
2050H loss or accurately dehydration due
dehydration to fever.
Paracetamol Used to Proper To treat patients
treat fever medication fever and mild
or mild and administration headache.
moderate
pain
Theoretical Framework

The Adaptation Model of Nursing was developed by

Sister Calista Roy in 1975. The key concepts of Roy’s
Adaptation Model are made up of four components: person,
health, environment, and nursing. According to Roy’s model,
a person is a bio-psycho-social being in constant interaction
with a changing environment. He or she uses innate and
acquired mechanism to adapt.
The goal of nursing is to promote adaptation in the four
adaptive modes. Nurses also promote adaptation for individuals
and groups in the four adaptive modes, thus contributing to
health, quality of life, and dying with dignity by assessing
behaviors and factors that influence adaptive abilities and by
intervening to enhance environmental interactions. The Four
Adaptive Modes of Roy’s Adaptation Model are physiologic
needs, self- concept, role function, and interdependence.

The Adaptation Model Includes a six-step nursing process:

1.) The first level of assessment, which addresses the patient’s
behavior
2.) The second level of assessment, which addresses the
patient’s stimuli
3.) Diagnosis of the patient
4.) Setting goals for the patient’s health
5.) Intervention to take actions in order to meet the goals
6.) Evaluation of the result to determine if goals were met.