Demographic data

Name: Address: Age: Gender: Birth Date: Birth Place: P nam p shone Dubinan East Santiago City 23 years old female June 21, 2004 Southern IsabelaGeneral Hospital(Emergency)

Marital Status: Married Nationality: Filipino

Ethnicity:ilocano Religion: Occupation: Chief complaint: fever, body weakness Final Diagnosis:Dfs Attending physician: Dr. Callang Initial Vital Signs: Blood Pressure: 100/70 mmHg Temperature: 36 C Pulse Rate: 98bpm Respiratory Rate:20cpm Scale of Pain: 3 abdomens (left lower Quadrant)

INTRODUCTION: Dengue fever is an infection disease carried by mosquitoes and caused by any vof four related dengue viruses. This disease used to be called break-bone fever because it sometimes causes severe joint and muscle pain feels like bones are breakin. Health experts have known about dengue fever for more than 200 years. dengue is an infectious caused by a virus. It occurs commonly as dengue fever. Occasionaly a patient. Suffering from adengue may develop bleeding are the nose,gums and skin. Sometimes, the patient may have coffe_ground vomiting or black stool. This indicates bleeding in the intestines. The patient with dengue fever who develops bleeding has dengue hemorrhagic fever (DHF). Dengue fever can be caused by any one of four types of dengue virus: DEN-1, DEN-2, DEN-3, and DEN-4. You can be infected by at least two, if not all four types at different times during your lifetime, but only once by the same type. You can get dengue virus infections from the bite of an infected Aedes mosquito. Mosquitoes become infected when they bite infected humans, and later transmit infection to other people they bite. Two main species of mosquito, Aedesaegypti and Aedesalbopictus, have been responsible for all cases of dengue transmitted in this country. Dengue is not contagious from person to person.
y y y y y

High fever, up to 105 degrees Fahrenheit Severe headache Retro-orbital (behind the eye) pain Severe joint and muscle pain Nausea and vomiting

Rash

Dengue fever is found mostly during and shortly after the rainy season in tropical and subtropical areas of
y y y y y y

Africa Southeast Asia and China India Middle East Caribbean and Central and South America Australia and the South and Central Pacific

An epidemic in Hawaii in 2001 is a reminder that many states in the United States are susceptible to dengue epidemics because they harbor the particular types of mosquitoes that transmit it. Worldwide, more than 100 million cases of dengue infection occur each year. This includes 100 to 200 cases reported annually to the Centers for Disease Control and Prevention (CDC), mostly in people who have recently traveled abroad. Many more cases likely go unreported because some health care providers do not recognize the disease. During the last part of the 20th century, many tropical regions of the world saw an increase in dengue cases. Epidemics also occurred more frequently and with more severity. In addition to typical dengue, dengue hemorrhagic fever and dengue shock syndrome also have increased in many parts of the world. Dengue fever can be caused by any one of four types of dengue virus: DEN-1, DEN-2, DEN-3, and DEN-4. You can be infected by at least two, if not all four types at different times during your lifetime, but only once by the same type. You can get dengue virus infections from the bite of an infected Aedes mosquito. Mosquitoes become infected when they bite infected humans, and later transmit infection to other people they bite. Two main species of mosquito, Aedesaegypti and Aedesalbopictus, have been responsible for all cases of dengue transmitted in this country. Dengue is not contagious from person to person. Symptoms of typical uncomplicated (classic) dengue usually start with fever within 5 to 6 days after you have been bitten by an infected mosquito and include
y y y y y y

High fever, up to 105 degrees Fahrenheit Severe headache Retro-orbital (behind the eye) pain Severe joint and muscle pain Nausea and vomiting Rash

The rash may appear over most of your body 3 to 4 days after the fever begins. You may get a second rash later in the disease. Symptoms of dengue hemorrhagic fever include all of the symptoms of classic dengue plus
y y

Marked damage to blood and lymph vessels Bleeding from the nose, gums, or under the skin, causing purplish bruises

This form of dengue disease can cause death. Symptoms of dengue shock syndrome-the most severe form of dengue disease-include all of the symptoms of classic dengue and dengue hemorrhagic fever, plus
y

Fluids leaking outside of blood vessels

y y

Massive bleeding Shock (very low blood pressure)

This form of the disease usually occurs in children (sometimes adults) experiencing their second dengue infection. It is sometimes fatal, especially in children and young adults.

http://health.nytimes.com/health/guides/disease/dengue-hemorrhagicfever/overview.html

http://www.nlm.nih.gov/medlineplus/ency/article/001373.htm http://www.slideshare.net/davejaymanriquez/dengue-hemorrhagic-fever-presentation883733 http://nursingcrib.com/case-study/dengue-fever-case-study/2/ http://health.nytimes.com/health/guides/disease/dengue-hemorrhagicfever/overview.html

Nursing History History of present illness According to her Grandmother, Few hours, Prior to check- Up the Patient was Playing around their surroundings when suddenly she feels difficulty of breathing, She went into their house and She complaintsthat she was tired of playing. She was rushed by her Grandmother at City Health Office of Santiago city. July 8 2011, She have check-Up under the service of Dr. Robelyn Devera Go, upon taking Vital Signs the Patient Body Temperature was 37.9 C the patient was advice to take Paracertamol 60 ml ,Guaifenesin + Salbutamol 60ml, Ascorbic Acid 120 ml and Catrimoxazole 60 ml Past medical History According to her Grandmother her OB History, She was delivered normally by her Mother in SIGH, Emergency Santiago city. She experienced Childhood illnesses such as Fever, Cough, Cold, and Mumps. She had completed her vaccines for Immunization. She doesnt have Food Allergies as well as Drug allergies. No Known Accident, Injuries and History of Animal Bites. Family Health History According to her Grandmother, the common disease that runs in their Family is High Blood. Her Father died at the age of 30 because of Cardiac Arrest. Her Grandfather from Fathers side is also Asthmatic and her grandmother is high blood. Her Mother is High blood. Her Grandmother from Mother Side is high blood and her Grandfather too. Her Brother has common cough and colds. Aside from that, there is no other disease known that runs in their family.

Gordons Functional Health Pattern

Health Perception- Health Management Pattern Before having Check-Up, the Patients health condition was good in spite of Asthma which according to her Grandmother the Asthma of the patient was a disease till birth until now. But she still have positive outlook of her condition. During Check Up, the Patient become more concern and conscious of her health and She is willing to participate in all the necessary Treatment, for her illness and still have a positive outlook in her condition She believed that by fallowing the orders of the physician, her condition will become better Nutritional- Metabolic Pattern Before hospitalization, the Patient consumes three meals a day. She usuallyeats Rice, Vegetables, Meat, Bangus, Chicken, and Fish. She has a Good appetite in eating. She can swallow liquids and solid foods and she can eat by herself. During Check-Up the patient was advice to get rest. She can still swallow liquids and solid foods but she eats with the help of her Grandmother Elimination Pattern Prior to Admission, the Patient defecates thrice a week and urinates at regular duration at day time. According to her Grandmother she has a negative defecation and has frequent urination Day and Night Sleep Rest Pattern According to Her, She usually sleeps at 9 pm. During Check Up According to her Grandmother the Patient hardly sleeps due to Asthma, Cough and fever. The Patient had irregular sleep Pattern because of Asthma. Activity- Exercise Pattern Before Check-Up, According to her Grandmother She wakes up early to play. She used to walk in the morning around their Backyard and she use to clean surroundings of their house. She always Play around playing pogs, jumping rope, and running. This serves as her daily activities and exercise every day. She watches television most of the time and make conversations with her Family and Friends. During Check-Up, She can still perform her daily activities with the help of others. She talks to her grandmother and visitors.

Cognitive-Perceptual The Patient is fluent in Tagalog; it is her Major form of Communication. During Check-Up. She was curious of her health and about the medications given to her. She can accommodate and answer correctly the questions asked to her even though she had difficulty. Self Perception- Self- Concept Pattern The Patient is curious with her health and Nutritional and intake because she want to maintain a good healthy lifestyle so that she could be able to perform her Daily Light Activities. According to her,she easily gets tired and when she felt difficulty of breathing she stop and take a rest. During Check Up she became more conscious about her health. Role relationship Pattern The Patient has one Brother; According to her grandmother the patient has a broken family. She was abandoned by her Mother and her Father died due to Cardiac Arrest. Now she is living with her Grandmother even though she has a broken family she still has a good family relationship. During Checkup, she was able to do her responsibility as a granddaughter and maintain secured relationship to everyone. Sexuality- Reproductive Pattern The Patient use to play a girl toys such as jumpingrope,Chinese garter, Pogs .At Present the patient has negative sexual activities because she is still in a young age. She makes conversation to her playmates and classmate doing those according to her it gives happiness to her Copying stress tolerance pattern The patient has a supportive family when it comes to trials that she encounter with the help of family members, the patient was able to handle problems and she always used to cry to relief her emotional and Physical problems. She also used to get out of their house to entertain herself. During Check-up the Patient experience stress due to health condition, She cope up the stress with the help of supportive grandmother, Family and still seek guidance from God.

Value and Belief Pattern

The Patient is an Santiagueio, According to her she asked guidance from their God and beliefs that she will gain help from their god that help her to overcome her present condition.. She has also values and Tradition of a Filipino Culture.

General Appearance The Patients is Pale and conscious. She has thin body built just not right for her height. She is well groomed.

a. Gender and Race b. Age c. d. e. 7 years old Signs of distress Shortness of breathing Body type Thin Posture Normal standing is an upright stance with parallel alignment of hips and shoulders Gait Movements are coordinate, she usually walks with arms swinging freely a the sides, with the head and face leading the body Body movements

f.

g.

h. Hygiene and grooming Clothes are clean, specially the nails. Hair are equally distributed and no dandruffs. Skin are brown it has a scar. i. j. Dress

Body odor Pleasant body odor, good hygiene, k. Affect and mood She expresses mood or emotional state verbally and non-verbally

l.

Speech

Normal speech.understandable and moderately pace. She talks slowly and clearly.

Vital signs: Blood Pressure: Body temperature: 38 C Pulse rate: 78 bpm Respiratory rate: 19 cpm Height: Weight: 18kgs

PHYSICAL ASSESSMENT

Body Part SKIN

Method Inspection

y y y y

Findings (+) scar (+) lesions (-) rashes Warm to touch

Interpretation d/t history of wounds d/t to playing NORMAL d/t increase release of pyrogens NORMAL NORMAL NORMAL

Palpation

Inspection

y y y

(-) pimples (-) lesions (+) facial sensation

Palpation

Inspection

y y y y

(-) lesion (-) dandruff (-) masses (-) tenderness

NORMAL NORMAL NORMAL NORMAL

Palpation

Inspection EYES y y y EARS y

Black in color

NORMAL

Pupils Conjunctiva Eyelids

Inspection Inspection Inspection

y y y

Dark brown in color PERRLA (2 3mm) (-) swelling

NORMAL NORMAL NORMAL

Auricles

Inspection Palpation

y y y

Uniform in color Firm Pinna recoils when folded (-) discharged (-) discharge

NORMAL NORMAL NORMAL

y NOSE

External ear

Inspection Inspection y y NORMAL NORMAL

y Palpation y y MOUTH y Lips y y y NECK Gums Tongue Teeth Inspection Inspection Inspection Inspection Inspection y y y y y y

(-) lesions (-) masses (-) tenderness Pink in color Uniformly brown in color Pink (+) tooth decay (-) lesions Head is centered (-) palpable lymph nodes (-) masses (+) tenderness Symmetrical (-) lesions Equal chest expansion Clear sounds breath

NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL d/t poor hygiene NORMAL NORMAL

Palpation

NORMAL

y y y y y

NORMAL

CHEST

Inspection

NORMAL NORMAL NORMAL

Auscultation

NORMAL

Palpation

y y y y y

Regular rhythm Apical pulse felt Absence of spots/lesions (-) scar Flat Audible normal bowel sounds (-) tenderness Liver, bladder

NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL

ABDOMEN

Inspection

Auscultation

Palpation

y y

NORMAL NORMAL

EXTREMITIES y Upper

Inspection

y y y y

not palpable (+) scars (-) skin rashes (-) deformity (-) masses and tenderness (+) scar (-) masses and tenderness Convex curvature

d/t playing NORMAL NORMAL NORMAL

Palpation

Lower

Inspection Palpation

y y

d/t poor hygiene NORMAL

Nails

Inspection

NORMAL

3 sec. capillary refill

NORMAL

FEVER ASSESSMENT DIAGNOSI S PLANNING INTERVENTIO N Monitored temperature every 30minutes. RATIONALE EVALUATIO N After 30 minute on effective nursing interventio n the client was able to maintain core temperatur e within normal range of 37.5 C.

Subjective: Mainitangpakiramdamko as verbalized by the client

Objective: y flushed skin y warm to touch y restlessness V/s as follow: BP: RR: 19 cpm PR: 78 bpm BP: 38 C

After 30 minute. Of nursing interventio n the client will maintain core temperatur e within normal range of 37.5 C from 38 C.

Provided surface cooling such as TSB and removing of extra clothing.

To obtain an accurate core temperatur e and detect for further developmen t. To promote core cooling by helping reduce temperatur e.

Promote rest and comfort providing bed To detect further rest. existing discomfort and level whether increased or decreased. Encouraged increase in To prevent fluid intake. dehydration because increase in body temp. causes fluid loss such as sweating Wrap extremities To minimize with cotton shivering. blankets.

ASSESSSMENT

DIAGNOSI S

PLANNING

INTERVENTIO N

RATIONALE

EVALUATIO N

Subjective: hindiakomakatulogdahilsaubo ko as verbalized by the patient. Objective: y y fatigue Dsynea V/S taken as follow: BP: PR: 78 bpm RR: 19 cpm BT: 38 C

Activity intoleranc e related to exhaustion associated with interruptio n in usual sleep pattern because of discomfort excessive coughing.

After 4 hours of nursing interventio ns the patient will demonstrat ea measurable increase in tolerance in activity with absence of dyspnea.

Evaluate patient s response to activity.

Establishes patients capabilities or need and facilitate choice if intervention . Facilitates healing process and enhances natural resistance.

Encourage adequate rest balanced with moderate activity. Promote adequate nutritional intake. Provide a quiet environment and limit visitors during acute phase.

After 4 hours of nursing interventio n the patient was able to demonstrat ea measurable increase in tolerance in activity with absence of dyspnea.

Reduces stress and excess stimulation promotion rest.