RESOURCE UNIT General Objective: After 2 hours of varied teaching-learning strategies, the BSN 3 section C students will be able

to gain knowledge, beginning skills and positive attitude towards the concept of Dengue Hemorrhagic Fever. Specific Objectives
Specifically the BSN 3C students will be able to : 1. Define and familiarize the following terms:

Contents

Methodolo gy Lecture demonstrati on

Time Allotment

Resources http://www.medicinenet.co m/dengue_fever/article.htm http://en.wikipedia.org/wiki /Dengue_fever

Evaluatio n

DEFINITION OF TERMS: Pathognomonic - is a sign or symptom that is so characteristic of a disease that it makes the diagnosis. Hermans sign - appears on the upper and lower extremities, purplish or violaceous red with blanched areas about 1 cm or less in size. tourniquet test (also known as a Rumpel-Leede Capillary-Fragility Test or simply a capillary fragility test) - determines capillary fragility. It is a clinical diagnostic method to determine a patient's haemorrhagic tendency. It assesses fragility of capillary walls and is used to identify thrombocytopenia (a reduced platelet count). - The test is defined by the WHO as one of the necessary requisites for diagnosis of Dengue fever. A blood pressure cuff is applied and inflated to a point between the systolic and diastolic blood pressures for five minutes. The test is positive if there are 10 or more petechiae per square inch. In DHF the test usually gives a definite positive result with 20 petechiae or more

5 mins http://www.scribd.com/doc/ 27500203/DENGUEHEMORRHAGIC-FEVERPATHOPHYSIOLOGY http://www.ehow.com/abou t_4674809_pathophysiolog y-dengue-hemorrhagicfever.html http://www.nlm.nih.gov/me dlineplus/ency/article/0013 73.htm http://emedicine.medscape. com/article/215840overview

Grade 3 dengue hemorrhagic fever a stage in DHF wherein patient will manifest fever, hermans sign, bleeding, melena, and circulatory collapse Fumigation is a method of pest control that completely fills an area with gaseous pesticidesor fumigantsto suffocate or poison the pests within.
2. Provide an introduction on dengue hemorrhagic fever

http://www.wisegeek.com/ what-is-dengue-fever.htm

5 mins.

Dengue fever also known as breakbone fever, is an acute febrile infectious disease caused by the dengue virus. Typical symptoms include headache, a petechial rash, and muscle and joint pains; in a small proportion the disease progresses to life-threatening complications such as dengue hemorrhagic fever (which may lead to severe hemorrhage) and dengue shock syndrome (where a very low blood pressure can cause organ dysfunction).Dengue is usually transmitted by the mosquito Aedes aegypti, and rarely Aedes albopictus. The virus has four different serotypes, and an infection with one usually gives lifelong immunity to it, but only short-term immunity to the others. There is currently no available vaccine, but outbreaks can be prevented by reducing the habitat and number of mosquitoes, and limiting exposure to bites. Dengue is prevalent throughout the tropics and subtropics. Outbreaks have occurred recently in the Caribbean, including Puerto Rico, the U.S. Virgin Islands, Cuba, and Central America. Cases have also been imported via tourists returning from areas with widespread dengue, including Tahiti, Singapore, the South Pacific, Southeast Asia, the West Indies, India, and the Middle East (similar in distribution to the areas of the world that harbor malaria and yellow fever). Dengue is now the leading cause of acute febrile illness in U.S. travelers returning from the Caribbean, South America, and Asia.

3. Determine the anatomy and physiology of the Blood.

20 mins. Anatomy and Physiology of Dengue Hemorrhagic Fever: Blood is a specialized bodily fluid that delivers necessary substances to the body's cells (in animals) such as nutrients and oxygen and transports waste products away from those same cells. Blood is composed of blood cells suspended in a liquid called blood plasma. Plasma, which constitutes 55% of blood fluid, is mostly water (92% by volume), and contains dissipated proteins, glucose, mineral ions, hormones, carbon (plasma being the main medium for excretory product transportation),platelets and blood cells themselves. The blood cells present in blood are mainly red blood cells (also called RBCs or erythrocytes) and white blood cells, including leukocytes and platelets. The most abundant cells in vertebrate blood are red blood cells. These contain hemoglobin, an iron-containing protein, which facilitates transportation of oxygen by reversibly binding to this respiratory gas and greatly increasing its solubility in blood. In contrast, carbon dioxide is almost entirely transported extracellularly dissolved in plasma as bicarbonate ion. White blood cells help to resist infections and parasites. Platelets are important in the clotting of blood. Blood is circulated around the body through blood vessels by the pumping action of the heart. In animals with lungs, arterial blood carries oxygen from inhaled air to the tissues of the body, and venous blood carries carbon dioxide, a waste product of metabolism produced by cells, from the tissues to the lungs to be exhaled. Medical terms related to blood often begin with hemo- or hemato- (also spelled haemo- andhaemato-) from the Ancient Greek word (haima) for "blood". In terms of anatomy and histology, blood is considered a specialized form of connective tissue,

given its origin in the bones and the presence of potential molecular fibers in the form of fibrinogen. Function: Blood accounts for 8% of the human body weight, with an average density of approximately 1060 kg/m3, very close to pure water's density of 1000 kg/m3. The average adult has a blood volume of roughly 5 liters (1.3 gal), composed of plasma and several kinds of cells (occasionally called corpuscles); these formed elements of the blood are erythrocytes (red blood cells), leukocytes (white blood cells), and thrombocytes (platelets). By volume, the red blood cells constitute about 45% of whole blood, the plasma about 54.3%, and white cells about 0.7%. Whole blood (plasma and cells) exhibits nonNewtonian, viscoelastic fluid dynamics; its flow properties are adapted to flow effectively through tiny capillary blood vessels with less resistance than plasma by itself. In addition, if all human hemoglobin were free in the plasma rather than being contained in RBCs, the circulatory fluid would be too viscous for the cardiovascular system to function effectively. Cells One microliter of blood contains: 4.7 to 6.1 million (male), 4.2 to 5.4 million (female) erythrocytes: In most human, mature red blood cells lack a nucleus and organelles. They contain the blood's hemoglobin and distribute oxygen. The red blood cells (together with endothelial vessel cells and other cells) are also marked byglycoproteins that define the different blood types. The proportion of blood occupied by red blood cells is referred to as the hematocrit, and is normally about 45%. The combined surface area of all red blood cells of the human body would be roughly

2,000 times as great as the body's exterior surface. 4,00011,000 leukocytes: White blood cells are part of the immune system; they destroy and remove old or aberrant cells and cellular debris, as well as attack infectious agents (pathogens) and foreign substances. The cancer of leukocytes is called leukemia. 140,000400,000 thrombocytes: thrombocytes, also called platelets, are responsible for blood clotting (coagulation). They change fibrinogen into fibrin. This fibrin creates a mesh onto which red blood cells collect and clot, which then stops more blood from leaving the body and also helps to prevent bacteria from entering the body. Plasma About 55% of whole blood is blood plasma, a fluid that is the blood's liquid medium, which by itself is straw-yellow in color. The blood plasma volume totals of 2.73.0 liters (2.83.2 quarts) in an average human. It is essentially an aqueous solution containing 92% water, 8% blood plasma proteins, and trace amounts of other materials. Plasma circulates dissolved nutrients, such as glucose, amino acids, and fatty acids (dissolved in the blood or bound to plasma proteins), and removes waste products, such as carbon dioxide, urea, and lactic acid. Other important components include: Serum albumin Blood-clotting factors (to facilitate coagulation) Immunoglobulins (antibodies) lipoprotein particles Various other proteins Various electrolytes (mainly sodium and chloride) The term serum refers to plasma from which the clotting proteins have been removed. Most of the proteins remaining are albumin and immunoglobulins. Physiology:

Cardiovascular system Blood is circulated around the body through blood vessels by the pumping action of the heart. In humans, blood is pumped from the strong left ventricle of the heart through arteries to peripheraltissues and returns to the right atrium of the heart through veins. It then enters the right ventricleand is pumped through the pulmonary artery to the lungs and returns to the left atrium through thepulmonary veins. Blood then enters the left ventricle to be circulated again. Arterial blood carries oxygen from inhaled air to all of the cells of the body, and venous blood carries carbon dioxide, a waste product of metabolism by cells, to the lungs to be exhaled. However, one exception includes pulmonary arteries, which contain the most deoxygenated blood in the body, while the pulmonary veins contain oxygenated blood. Additional return flow may be generated by the movement of skeletal muscles, which can compress veins and push blood through the valves in veins toward the right atrium. Production and degradation of blood cells The various cells of blood are made in the bone marrow in a process called hematopoiesis, which includes erythropoiesis, the production of red blood cells; and myelopoiesis, the production of white blood cells and platelets. During childhood, almost every human bone produces red blood cells; as adults, red blood cell production is limited to the larger bones: the bodies of the vertebrae, the breastbone (sternum), the ribcage, the pelvic bones, and the bones of the upper arms and legs. In addition, during childhood, the thymus gland, found in the mediastinum, is an important source of lymphocytes. The proteinaceous component of blood (including clotting proteins) is produced predominantly by the liver, while hormones are produced by the endocrine glands and the watery fraction is regulated by

the hypothalamusand maintained by the kidney. Healthy erythrocytes have a plasma life of about 120 days before they are degraded by the spleen, and the Kupffer cells in the liver. The liver also clears some proteins, lipids, and amino acids. The kidney actively secretes waste products into the urine. Lymphatic system In mammals, blood is in equilibrium with lymph, which is continuously formed in tissues from blood by capillary ultrafiltration. Lymph is collected by a system of small lymphatic vessels and directed to the thoracic duct, which drains into the left subclavian vein where lymph rejoins the systemic blood circulation. Thermoregulation Blood circulation transports heat throughout the body, and adjustments to this flow are an important part of thermoregulation. Increasing blood flow to the surface (e.g., during warm weather or strenuous exercise) causes warmer skin, resulting in faster heat loss. In contrast, when the external temperature is low, blood flow to the extremities and surface of the skin is reduced and to prevent heat loss and is circulated to the important organs of the body, preferentially. Hydraulic functions The restriction of blood flow can also be used in specialized tissues to cause engorgement, resulting in an erection of that tissue; examples are the erectile tissue in the penis and clitoris. Another example of a hydraulic function is the jumping spider, in which blood forced into the legs under pressure causes them to straighten for a powerful jump, without the need for bulky muscular legs. White blood cells (WBCs), or leukocytes: Also spelled "leucocytes," "leuco-" being Greek for white, are cells of

the immune system involved in defending the body against both infectious disease and foreign materials. Five different and diverse types of leukocytes exist, but they are all produced and derived from a multipotent cell in the bone marrow known as a hematopoietic stem cell. Leukocytes are found throughout the body, including the blood and lymphatic system. The number of WBCs in the blood is often an indicator of disease. There are normally between 4109 and 1.11010 white blood cells in a litre of blood, making up approximately 1% of blood in a healthy adult. An increase in the number of leukocytes over the upper limits is calledleukocytosis, and a decrease below the lower limit is called leukopenia. The physical properties of leukocytes, such as volume, conductivity, and granularity, may change due to activation, the presence of immature cells, or the presence of malignant leukocytes in leukemia. Types There are several different types of white blood cells. They all have many things in common, but are all distinct in form and function. A major distinguishing feature of some leukocytes is the presence of granules; white blood cells are often characterized as granulocytes or agranulocytes: Granulocytes (polymorphonuclear leukocytes): leukocytes characterised by the presence of differently staining granules in their cytoplasm when viewed under light microscopy. These granules are membrane-bound enzymes which primarily act in the digestion ofendocytosed particles. There are three types of granulocytes: neutrophils, basophils, and eosinophils, which are named according to their staining properties. Agranulocytes (mononuclear leucocytes): leukocytes characterized by the apparent absence of granules in their cytoplasm. Although the name implies a lack of granules these cells do contain non-

specific azurophilic granules, which are lysosomes. The cells includelymphocytes, monocytes, and macrophages. Neutrophil Neutrophils defend against bacterial or fungal infection and other very small inflammatory processes that are usually first responders to microbial infection; their activity and death in large numbers forms pus. They are commonly referred to as polymorphonuclear (PMN) leukocytes, although technically PMN refers to all granulocytes. They have a multilobed nucleus which may appear like multiple nuclei, hence the name polymorphonuclear leukocyte. The cytoplasm may look transparent because of fine granules that are pale lilac. Neutrophils are very active in phagocytosing bacteria and are present in large amount in the pus of wounds. These cells are not able to renew theirlysosomes used in digesting microbes and die after having phagocytosed a few pathogens. Most common cell seen in acute inflammation, comes in and kill foreign substance.They make up 6070% of total leukocyte count.The life span of neutrophil is about 8 days. Eosinophil Eosinophils primarily deal with parasitic infections and an increase in them may indicate such. Eosinophils are also the predominant inflammatory cells in allergic reactions. The most important causes of eosinophilia include allergies such as asthma, hay fever, and hives; and also parasitic infections. Generally their nucleus is bi-lobed. The

cytoplasm is full of granules which assume a characteristic pink-orange color with eosin stain. Basophil Basophils are chiefly responsible for allergic and antigen response by releasing the chemical histamine causing inflammation. The nucleus is bi- or tri-lobed, but it is hard to see because of the number of coarse granules which hide it. They are characterized by their large blue granules. Lymphocyte Lymphocytes are much more common in the lymphatic system. Lymphocytes are distinguished by having a deeply staining nucleus which may be eccentric in location, and a relatively small amount of cytoplasm. The blood has three types of lymphocytes: B cells: B cells make antibodies that bind to pathogens to enable their destruction. (B cells not only make antibodies that bind topathogens, but after an attack, some B cells will retain the ability to produce an antibody to serve as a 'memory' system.) T cells: CD4+ (helper) T cells co-ordinate the immune response and are important in the defense against intracellular bacteria. In acute HIV infection, these T cells are the main index to identify the individual's immune system activity. Research has shown that CD8+ cells are also another index to identify human's immune activity. CD8+ cytotoxic T cells are able to kill virus-infected and tumor cells. T cells possess an alternative T cell receptor as opposed to CD4+ and CD8+ T cells and share characteristics of helper T cells, cytotoxic T cells and natural killer cells.

Natural killer cells: Natural killer cells are able to kill cells of the body which are displaying a signal to kill them, as they have been infected by a virus or have become cancerous. Monocyte Monocytes share the "vacuum cleaner" (phagocytosis) function of neutrophils, but are much longer lived as they have an additional role: they present pieces of pathogens to T cells so that the pathogens may be recognized again and killed, or so that an antibody response may be mounted. Monocytes eventually leave the bloodstream to become tissue macrophages which remove dead cell debris as well as attacking microorganisms. Neither of these can be dealt with effectively by the neutrophils. Unlike neutrophils, monocytes are able to replace theirlysosomal contents and are thought to have a much longer active life. They have the kidney shaped nucleus and are typically agranulated. They also possess abundant cytoplasm. Once monocytes move from the bloodstream out into the body tissues, they undergo changes (differentiate) allowing phagocytosis and are then known as macrophages. (Pls see overview of types of WBC on Appendix A) (http://en.wikipedia.org/wiki/Blood) (http://en.wikipedia.org/wiki/White_blood_cells)
4. Establish the pathophysio logy of DHF

15 mins.

5 mins.

( Pls see attached PATHOPHYSIOLOGY on Appendix B) Dengue infection is caused by 1 of 4 related, but antigenically distinct, viral serotypes: dengue virus 1 (DENV-1), dengue virus 2 (DENV-2), dengue virus 3 (DENV-3), and dengue virus 4 (DENV-4). Albert Sabin speciated these in 1944. Each serotype is known to have several different genotypes. Dengue viruses are small, spherical, singlestranded enveloped RNA viruses of the family Flaviviridae, genus Flavivirus.

Infection with one dengue serotype confers lifelong homotypic immunity and a very brief period of partial heterotypic immunity, but each individual can eventually be infected by all 4 serotypes. Several serotypes can be in circulation during an epidemic. Dengue viruses are transmitted by the bite of an infected Aedes mosquito. Globally, a aegypti is the predominant highly efficient mosquito vector for dengue infection, but A albopictus and other Aedes species can also transmit dengue with varying degrees of efficiency. Aedes mosquito species have adapted well to human habitation, often breeding around dwellings in small amounts of stagnant water found in old tires or other small containers discarded by humans. Female Aedes mosquitoes are daytime feeders. They inflict an innocuous bite and are easily disturbed during a blood meal, causing them to move on to finish a meal on another individual, making them efficient vectors. Entire families who develop infection within a 24- to 36-hour period, presumably from the bites of a single infected vector, is not unusual. Humans serve as the primary reservoir for dengue; however, certain nonhuman primates in Africa and Asia also serve as hosts. Mosquitoes acquire the virus when they feed on a carrier of the virus. The mosquito can transmit dengue if it immediately bites another host. In addition, transmission occurs after 8-12 days of viral replication in the mosquitos salivary glands (extrinsic incubation period). The mosquito remains infected for the remainder of its 15- to 65-day lifespan. Vertical transmission of dengue virus in mosquitoes has been documented. The eggs of Aedes mosquitoes withstand long periods of desiccation, reportedly as long as 1 year, but are killed by temperatures of less than 10C. Once inoculated into a human host, dengue has an incubation period of 3-14 days (average 4-7 d). Following incubation, a 5- to 7-day acute febrile illness ensues. Recovery is usually complete by 7-10 days. DHF or DSS usually develops around the third to seventh day of illness,

5 mins.

approximately at the time of defervescence. The major pathophysiological abnormalities that occur in DHF and DSS are plasma leakage and bleeding. Plasma leakage is caused by increased capillary permeability and may be manifested by hemoconcentration, as well as pleural effusion and ascites. Bleeding is caused by capillary fragility and thrombocytopenia and may present various ways, ranging from petechial skin hemorrhages to life-threatening gastrointestinal bleeding. Most patients who develop DHF or DSS have had prior infection with one or more dengue serotypes. In individuals with low levels of neutralizing antibodies, nonneutralizing antibodies to one dengue serotype, when bound by macrophage and monocyte Fc receptors, have been proposed to result in increased viral entry and replication, and increased cytokine production and complement activation. This phenomenon is called antibody-dependent enhancement. In addition, certain dengue strains, particularly those of DEN-2, have been proposed to be more virulent, in part because more epidemics of DHF have been associated with DEN-2 than with the other serotypes.
5. Enumerate the different signs and symptoms of DHF

Dengue Hemorrhagic Fever Clinical Manifestations, Signs and Symptoms: Once infection occurs, the time it takes symptoms to develop, known as the incubation period, depends upon the virus and its rate of growth in human tissues. In addition to fever and severe muscle pain, persons with hemorrhagic fever often develop bloodshot eyes and redness of the face and upper body. They may experience vomiting, diarrhea, and mild, general edema (swelling caused by accumulation of fluids in tissue spaces). Tiny, pinpoint-sized purple or red spots on the skin,

known as petechiae, are also common. As the infection progresses, it often impairs the bloods ability to clot. The walls of the capillaries (smallest blood vessels) may be damaged, permitting blood to escape and causing hemorrhaging (excessive bleeding). The amount of blood circulating through the body is reduced, sometimes producing shock, characterized by pale, cold extremities; a rapid, weak pulse; and falling blood pressure. The incubation period of DHF is two to seven days. In the early stages the symptoms are very similar to those of dengue fever. The second stage symptoms include nausea, vomiting, and abdominal pain. The onset of hemorrhagic symptoms rapidly followsbleeding nose and gums, bruising easily, and sometimes internal bleeding. The amount of blood circulating through the body is reduced, sometimes producing shock, characterized by pale, cold extremities; a rapid, weak pulse; and falling blood pressure. Treatment for these symptoms is a standard fluid rehydration therapy in order to maintain blood pressure. If circulatory failure is not reversed, death may follow. DHF is most common among children under the age of 15. Ten percent of childhood cases of DHF are fatal. GENERAL DATA PATIENTS PROFILE NAME : J.G.C. ADDRESS : Baha-Baha Tayud, Consolacion, Cebu AGE : 3 years old BIRTHDATE : 04/13/2007 PLACE OF BIRTH : Cebu City STATUS : Child CITIZENSHIP : Filipino

10 mins.

6. Present the general data, HPI, chief complaints of patient with DHF.

RELIGION : Roman Catholic SPOUSE : N/A SEX : MALE OCCUPATION : N/A PHYSICIAN : Dr. EDWARD Chua ADMISSION DATE : 1/15/2011 ADMISSION TIME : 10:14AM HOSPITAL NO. : 294612 WARD NO. : CW27 HISTORY OF PRESENT ILLNESS: A Case of J.G.C., 3 yrs. Old, Roman Catholic, residing at Baha-Baha Tayud, Consolacion, Cebu, was admitted due to high fever. Five days prior to admission, patient had onset of high grade fever with temperature of 39.9oC, temporary relieved with Ibuprofen (Dalan) 5ml associated with vomiting, coryza, body malaise, headache, and epigastric pain and anorexia. Consult done with AP and was given Advil 5 ml, Neozep 5 ml, Salbutamol 5 ml. One day prior to admission, fever persisted still associated with coryza, vomiting, body malaise, headache, epigastric pain and anorexia despite compliance of medication. No epistaxis. No any other bleeding episodes. No cough. Morning prior to admission, persistence of condition prompted consult with another AP. CBC was taken and revealed thrombocytopenia, however unrecalled. Patient was given anti-TB meds due to LAD findings, co-amoxiclav and zinc. Patient was advised for admission.

CHIEF COMPLAINTS: fever, body malaise, headache, epigastric pain. Past Health history: On his early childhood, He experienced illness such as measles, mumps, and chicken pox. When he had a fever, her mother wiped his whole body to relieve the heat. He sometimes had headache and diarrhea but he will just take a medicine for it. He was able to complete his immunization and he does not have any allergies to foods and drugs. He was not able to undergo any operations, accidents or traumatic conditions. But he was admitted last 2008 when he was still 9 months old and 1 year old due pneumonia. GORDON'S FUNCTIONAL HEALTH PATTERN 1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN Before hospitalization, the patient's mother verbalized that her son really had a good health. Though at times, her son would have fever, colds and cough; the family was still able to cure them through proper diet, rest, and self-medication. The mother also verbalized that though they don't have an annual check-up of their son since it would just cost them another peso, she made sure that her son has really gotten the complete immunization. While admitted at the hospital, the patient's mother verbalized that she would still describe her son's health GOOD. She believed that the physician's expertise together with their complete cooperation to the treatment regimen was really essential to the fast recovery of their son.

7. Establish the Gordons functional health patterns of the patient.

2. NUTRITIONAL-METABOLIC PATTERN Before hospitalization, the patient's mother shared that her son would really eat three times a day with snacks in between each meals. The patient loves eating fried chicken and adobong baboy and usually have biscuits and/or bread during his snacks. The patient would, most of the time, consume at least three bottles of milk (Lactum) and four to six glasses of water in a day. While admitted at the hopital, the patient's mother shared that her son was still eating three times a day but by this time seldom had snacks because in between nine to ten in the morning or three to four in the afternoon, the patient usually takes a nap. The patient also by this time only consumed only one to two bottles of milk (Lactum still) and two to four glasses of water in a day. 3.ELIMINATION PATTERN Before hospitalization, the patient's mother uttered that her son would usually urinate three to five times in a day (color: dark to light yellow, amount: half a glass every urination) without feeling any pain. The patient defacates once or twice in a day. While admitted at the hospital, the patient's mother uttered that her son would still urinates three to five times a day (color: dark to light yellow, amount: half a glass every urination) without feeling any pain and defacates still one to two times a day. 4. ACTIVITY-EXERCISE PATTERN Before hospitalization, the patient's mother put into words that her son after waking up, eating his breakfast and bathing would immediatly go to his playmates just near their place and play games (usually slipper games).

10 mins.

While admitted at the hospital, the patient's mother put into words that her son would really want to play outside but what else should they do since they were admitted, she just brought along with them some of the patient's toys. As a child's exercise, she lets her son walk within the pedia ward. 5. SLEEP-REST PATTERN Before hospitalization, the patient's mother told that her son would usually sleep at around eight in the evening and wakes up at around six:thirty in the morning with one to two hours of nap in the afternoon. The patient upon sleeping would really request her mom to lie beside him until he's totally asleep. While admitted at the hospital, the patient's mother told that her son sleeps at around seven in the evening and wakes up at six in the morning with one hour of nap both in the morning and afternoon. 6. COGNITIVE-PERCEPTION PATTERN The patient's mother shared that the patient's still not able to read and write though she is starting to teach him with the alphabet and some of the nursery rhymes. The patient does not have any deficits in sensory perception. 7. SELF-PERCEPTION PATTERN The patient's mother verbalized that whenever her son would be ill, her son would always equate being ill to punishment of his bad doings while if he's totally healthy, he would always equate it as a reward to his good deeds. 8.ROLE-RELATIONSHIP MODEL The patient communicates wIth his family through verbal and non-verbal cues using the vernacular language with a little mixture of

english. The patient is living together with his two other siblings and his father. 9. SEXUALITY-REPRODUCTIVE PATTERN Not Applicable 10. COPING-STRESS MANAGEMENT PATTERN When the patient is seemed to be stressed like when giving medications or IV insertion, and among many others; her mother would just try to ease him through back rubbing, saying good words, offering toys and providing rewards. 11.VALUE-BELIEF SYSTEM The patient's mother revealed that their family's greatest source of strength is nobody but our God Almighty. The mother always put an emphasis on the family's strong bond with Him as evidenced by their prayers. The patient greatly believes in Him and the mother confessed that without Him, they could not have the kind of life that they have right now though not perfect. PHYSICAL EXAMINATION
8. Provide a physical assessment of the patient.

10 mins.

15 mins.

10 mins.

5 mins. 5 mins.

GENERAL OBSERVATION: Received patient lying on bed, conscious, coherent, oriented, with an IVF of PNSS @ left arm with the rate of 10 gtts/min and voluven on the right arm having the same rate. Sunken eyes and dry skin are noted but no guarded movements. CRT is less than two seconds. Patient is also noted to be weak. SKIN: Skin color is brown and dry. He has multiple punctured wounds from the CBC test and IVF insertion, he has warm skin and it goes back after being pinched in two seconds or less. Patient has scar on the left knee.

HAIR: Hair is black in color, and is evenly distributed. It is straight. It is also free from infection or any infestations. SCALP: Scalp is slightly dry. No lesion/masses noted. NAILS: Nail bed is slightly pale, the angle between the fingernail and base is about 160. Nail base is firm. FACE: The face of the patient is symmetrical, free from edema and masses. EARS: The ears are symmetrical, flesh in color, free from swelling, no discharges noted. EYES: His eyes could follow the pen in all directions. No excessive tearing noted, no redness, free from lesions and masses. NOSE: Nose is symmetrical, located midline of the face. It is free from inflammation, swelling, bleeding, lesions and discharges. MOUTH AND PHARYNX: Lips are noted pale with dry mucosa. Tongue lies midline with free mobility. NECK: Muscles are symmetrical with head in central position. Movement can be done through full range of motion. CHEST: Posterior thorax rises and fall in union with respiratory cycle. The ratio of anterior to lateral diameter ranges from 1:2. HEART: Aortic is louder than pulmonic because of the greater pressure in the

left side of the heart. VASCULAR SYSTEM: There is absence of bulging. No noted enlargement of the legs. No distended vein noted. LYMPHATIC SYSTEM: Lymphatic nodes are non palpable, superficial inguinal nodes are also not palpable. BREAST: non-tender, no discharges noted, absence of lumps, free from lesions and masses. ABDOMEN: Umbilicus is midline of the abdomen evident of respiration movement. GENITALIA: No FBC inserted. EXTREMITIES: No gross deformities, nail beds slightly pale in color.
9. Present the study of the drugs and IVF taken by the patient. 10. Provide a nursing care plan applicable fot he patient 11. Identify a

Please see DRUG STUDY and IVF STUDY on Appendix C

Please see NCP on Appendix D

discharge plan for the patient.

Please see Discharge Plan on Appendix E Please see doctors order on Appendix F Please see laboratory results on Appendix G

Appendix A: OVERVIEW of WBC

Approx. % in Diamete Main targets adults[6] r (m)
See also: Blood values

Type

Microscopic Appearance

Diagram

Nucleus

Granule Lifetime s

Neutroph il

5462%

1012

bacteria fungi

fine, faintly multilobe pink d (H&E Stain)

6 hours few days (days inspleen an d other tissue)

Eosinoph il

16%

1012

full of 812 days pink(circulate bi-lobed orange for 45 modulate allergicinflammatory re (H&E hours) Stain) sponses larger parasites bi-lobed large ortriblue lobed a few hours to a few days

Basophil

<1%

1215

release histamine forinflammator

y responses

B cells: releases antibodies and

assists activation of T cells

T cells:

Th (T helper) cells:

activate and regulate T and B cells

Lymphoc yte 2533% 78

CD8+ cytotoxic

T NKcells and deeply Cytotoxi weeks staining, c years eccentric (CD8+) T-cells

cells: virus-infected and tumor cells.

to

T cells: Regulatory

(suppressor) T cells: Returns the functioning of the immune

system to normal operation after infection; preventsautoimmunity

Natural killer cells:virus-infected

and tumorcells.

Monocyt e

210%

1417

Monocytes migrate from the bloodstream to kidney other tissues and differentiate into tissue shaped resident macrophages or dendritic cells.

hours days

to

Macroph age

Phagocytosis (engulfment and digestion) of 21 cellular debris and pathogens, and stimulation (human) of lymphocytesand other immune cells that respond to the pathogen.

none

activated: days immature: months to years

Dendritic cells

Main function is as anantigen-presenting cell(APC) that activates T lymphocytes.

similar to macropha ges

Appendix B: PATHOPHYSIOLOGY

Pathophysiology on Dengue Hemorrhagic Disease

Predisposing: Geographical area-tropical islands In the pacific (Philippines) Precipitating: environmental conditions (open spaces with water, pots, and plants ; sweaty skin Immunocompromise; mosquito carrying dendue virus

Aedes aegypti(dengue virus carrier: 8-12 days of viral replication andmosquitos salivary glands. Bite from mosquito (portal of entry in the skin) Allowing dengue virus to be inoculated toward the circulation (incubation period: 3-14 days) Virus disseminated rapidly into the blood and stimulates WBC including B lymphocytes that produces and secretes immunoglobulins(antibodies), and monocytes, macrophages, neutrophils. diagnostic: HEMATOLOGY: WBC; Lymphocytes redness and itchiness in the area

Diagnostic : HEMATOLOGY Monocytes; neutrophils

Antibodies attach to the viral antigens, and then monocytes/macrophages will perform phagocytosis

through Fc receptor (FcR) within the cells and

entry to the spleen

entry to the bone marrow

dengue virus replicate in the cells.

Recognition of Dengue viral antigen on infected monocyte. Release of cytokines which consult of vasoactive agents such as interleukins, tumor necrosis factor, urokinase and platelet-activating factors which stimulates WBCs and pyrogen release.

Signs and symptoms: Febrile, diaphoresis, Warm skin, malaise, (+) tourniquet test

DENGUE

Virus ultimately targets liver and spleen Parenchymal cells where infection Produces apoptosis/cell death. Hepatosplenomegaly HEMATOLOGY:

Cellular direct destruction infection of red bone marrow precursor cells as well as immunological Shortened platelet Thrombocytopenia diagnostics : Platelets S/S: red eyes, petechiae

S/S: abdominal pain

Generic and Brand name

Dose,strength And formulation

DENGUE HEMMORHAG Appedix C: DRUGSTUDY and IVF STUDY Indication and mechanism of Adverse and side effect Nursing action of drug interaction Responsibilies

Rationale

Client Teaching

Generic: Ranitidine Brand: Zantac Classification: H2 antagonist

Ordered: 15 mg IVTT Timing: q 8 hrs Duration: 8-12 hrs

Indication: -for active treatment of duodenal ulcer -for benign gastric ulcer -for GERD

Cns: headache, malaise,dizziness CV:tachycardia, Bradycardia DERM: Rash,alopecia GI:constipation, Diarrhea,N/V

-administer with -to prevent gastic upset meals -to relieve pain -provide concurrent antacid

-take this with meals and at bedtimew -if you are using antacid,take exactly as prescribed -have regular medical follw-up

MOA: -inhibits the action of Other forms: histamine at the H2 receptor GU:Gynecomastia Tablets-75,150,300 of the parietal cells of the mg stomach Drug interaction: Granules- 25,150 Increased effects of Syrup- 15 mg/ml warfarin

-adm. IM dose undiluted -arrange regular follow-up

-for fast absorption -report sore -to know the throat,fever,bleeding effectiveness of the drug and tarry stools

IVF STUDY: Type of Classification Solution

Content

Mechanism of Action

Indications

Contraindicati ons

How Supplied

Dose

Nursing responsibility

0.9% PNSS

Isotonic Solution (isotonic crystalloid Solution)

Each 100 mL of 0.9 NaCl contains 900mg sodium chloridein water. Electrolytes per 1000mL sodium 154mEq, chloride 154 mEq. The osmolarity is 308 mOsmol/L (calc.) pH is 5-6 (4.5-7.0)

Provides fluid and electroly tes

IV lock and KVO for all patients Extracellula r fluid replacement when CIloss is equal or greater than Na loss. Treatment of metabolic Na depression, alkalosis. Initiating and terminating blood transfusion.

Unknown contraindicati ons

1000mL

80cc/hr

1. Tear outer wrap at notch and remove solution container. 2. Check for leaks by squeezing container firmly. If leaks are found discard unit as sterility may be impaired. If supplemental medication is desired, follow directions properly before preparing for administration. 3. Exposure of product to heat should be minimized. 4. Avoid exposure to heat and protect product from freezing. 5. Store at 20 degrees Celsius to 78 degrees Celsius (68-77F).

Appendix D: NURSING CARE PLAN Cues / Evidence Nursing Scientific Basis Diagnosis Subjective cues no subjective cues Objective cues*Warm to touch *Weakness noted *Latest platelet count of 54.0 K/UL as of January 19, 2011 at 4:00 AM w/ the ff. v/s: T-36.2C P-102 bpm R-32 cpm BP- 100/60 mmHg Risk for bleeding r/t thrombocytopenia 2 Dengue hemorrhagic fever Dengue fever is transmitted only through an infected mosquito or by contact with the blood of someone who is actively infected with one of the four viruses responsible for the fever. Infection with one of these viruses generally provides immunity from dengue fever for as much as a year after the illness. A small minority of cases of dengue fever develop into severe forms of the fever, DHF or

Goal & Outcome Criteria After 8 hrs. of nursing interventions the patient will demonstrate no bleeding episodes during the shift Outcome criteriaSpecifically the patient and mother will be able to 1. gain knowledge on the causes of DHF and ways of preventing its complication 2. Verbalize no signs of bleeding episodes

Nursing Action & Nursing Orders Nursing action: Perform nursing care and procedures to alleviate patients feeling and prevent from bleeding episodes Independent: *Assessed vital signs (BP,T,PR, RR)

Rationale of Nursing Orders

Evaluation After 6 hours of nursing interventions, the patient demonstrated no bleeding episodes during the shift

*Instruct to avoid procedures/ activities that can increase intracranial pressure ( coughing, straining to have a bowel movements to avoid intracranial bleeding *Instruct mother to avoid use of commercial mouthwash

-to have a baseline data for the treatment and signs of bleeding/shock (Brunners and Suddarths,12,957) -prevents intracranial bleeding (Brunners and Suddarths,12,957)

dengue shock syndrome, which require hospitalization. (Doenges,812,09)

3.. Shows cooperation in prevention and implementation of nursing task to prevent bleeding episodes

*Tell the patient and the mother not to brush teeth and not to nosepick *Instruct to eat no choco colored foods and to increase fluid intake -It can cause dryness to the mouth and increase *Avoid IM injections and any risk for bleeding. invasive procedures (Brunners and Suddarths,12,957) *Raise side rails -brushing and nosepicking can cause gum bleeding (Brunners and Suddarths,12,957) -to avoid misconception for GI *Visited at intervals bleeding (Brunners and Suddarths,12,957) *Monitored for any unusualities -decrease chance for intramuscular bleeding (Brunners and Suddarths,12,957) -to prevent from injury Independent: which increases the chance for bleeding * Avoid medications that (Brunners and interfere with platelet function if Suddarths,12,957)

possible( ASA, NSAIDs, betalactam antibiotics and Aspirin)

-for monitoring (Brunners and Suddarths,12,957) - to have immediate intervention when unusualities occurs (Brunners and Suddarths,12,957)

- decrease problem with platelet aggregation and adhesion (Brunners and Suddarths,12,957)

Appendix E: DISCHARGE PLAN DISCHARGE PLAN PATIENT NAME: J.G.C AGE: 63years old PHYSICIAN: Dr. E. CHUA IMPRESSION: DIAGNOSIS: DHF PATIENTS OUTCOME CRITERIA As soon as the patient is admitted and discharge from CHH, the patient and his family will be able to: ASSESSMENT: .assess vital signs before and after an activity Assess activity tolerance Teach patients parents the proper way of taking the vital signs. Instruct patients parents to have rest intervals between activities to avoid fatigue. HOSPITAL NO: 20080101000049 ROOM NO: CW27 NURSES SIGNATURE:

NURSING ORDER

PLANNING: Plan for scheduled visits as ordered by the physician Plan for activities to help educate the client

encouraged the patients parents to make calendar of activities or a diary to keep a planner Ask the client if he wants to cooperate with the plan to facilitate cooperation on the treatment. Teach the client how to take the medications and when to take them. discuss its side affects PRN Medication: Paracetamol 250/5 4 ml every 4 hrs for temp. >38C

IMPLENTATION: M-edication Administering of medication as prescribed

E-xercise Exercise daily to promote healthy lifestyle T-reatment Treat the primary cause of the problem

Demonstrate to the client how and what are the ways on doing the exercise appropriately for level of activity.

Enumerate to the client the existing of such condition and discuss its complications. Avoid things that could increase the risk for bleeding episodes Discuss to the client the techniques to promote wellness and prevent any complications like doing regular exercise and taking more fluids. *Instruct to avoid procedures/ activities that can increase intracranial pressure (coughing,

H-ealth teachings Educate patient on the rights and what must be done

straining to have a bowel movements to avoid intracranial bleeding). *Instruct mother to avoid use of commercial mouthwash *Tell the patient and the mother not to brush teeth and not to nosepick *Avoid IM injections and any invasive procedures Out-patient referral referral for any unusualities observed by the client Tell to the patients parents to observe any changes that are unusual and instruct to refer it if any. Instruct SO to always observe the patient and note for changes and progress. If complications noted, like bleeding refer it to the health care provider. Instruct to follow proper diet, to help body compensate.. diet as tolerated and must eat No Choco Colored foods to avoid misconception for GI bleeding. Patient should increase fluid intake and monitor urine output for signs of hematuria.

D-iet Food preferences may affect the recovery

EVALUATION: Evaluate self performance to the procedures previously taught. Accept his condition positively Encouraged the patients parents to make a diary of his daily activities and note his response in every activity Explore ways which significant others can be supportive.

APPENDIC F: DOCTORS ORDERS: Physicians Order patient name: Cuyos, 3M Date 1\15\11 10pm Dr. E Chua CW27

>pls admit under the service of Dr. E Chua >pls secure consent to care >DAT except dark colored foods >CBC, WT, V\S >Paracetamol 250\5 ml 4ml q 4 hrs for temp >38 >start IVF PNSS 500cc to 13gtts\min monitor v\s every hour >I&O of shift in absolute cc's >pls refer for narrow pulse pressure, weak pulse, bleeding episodes, cold extremities or any unusualities >pls promote a calibrated urine for proper collection and measurement of

clammy urine 11pm regulate output then chart at bedside. >insert another IV line with Voluven 500cc run 150cc as fast drip then to 20gtts\min >start dopamine at 4-5 cc\hr via infusor pump >Ranitidine 15 mg IVTT 8hrs >IVFTF # 2 PNSS @ 18gtts\min >for repeat CBC tomorrow at 4am 1\16\11 >to send 2 donors of patients blood type, screen and crossmatch >regulate ivf as follows R arm at 10gtts\min-voluven L arm at 10gtts\min-PNSS >repeat CBC at 5pm today >Facilitate urinalysis >IVFTF #3 w /PNSS @ 10 gtts\min >Voluven to follow #2 @10gtts\min Repeat CBC tomorrow 4am 1\17\11 >Dr. E. Chua made rounds >repeat CBC 4pm 1/17/11 >maw give furosemide 10g IVTT now! >Dopamine to 80cc/hr >Voluven 500cc @20gtts?min

1\16\11

1/17/11 (7:30am)

8 am 1/17/11 (3:50pm) >Dr. E. Chua updated. >Voluven rate to 10gtts(right arm) >Start PNSS (on left arm)at a rate of 10gtts/min, with piggyback Dopamine at 8cc/hr >repeat CBC @ 4am 1/18/11 tomorrow 6:45pm

1/17/11 >IVFTF #5: Voluven @ 10gtts/min (10:30pm) 10:35pm 1/18/11 >IVFTF #3: Dopamine drop @8cc/hr

(6:30am) 6:45am 1/18/11 >IVF rate of PNSS to 23cc/hr (1.5cc/khr) (8:20am) >IVF rate of Voluven to 23cc/hr(1.5cc/kg/hr) then temperature once consumed >Please inform/PROD once Voluven is consumed for re-adjustment of IVF rate 8:45am 1/18/11 >Dopamine rate to 5-6cc/hr (2:45pm) >repeat CBC today @4pm 1/18/11 4:15pm 1/18/11 (6:20pm) >Dopamine to 3-4cc/hr >repeat CBC @4am tomorrow 1/19/11 >Voluven to consume >Please inform PROD once Voluven is consumed >re-adjustment of IV rate >transfer to regular ward >discontinue Dopamine >to consume Voluven

7pm 1/18/11 (9pm) 9pm 1/18/11 >V/S monitoring to q4/hr (9pm) >IVFTF #5@ the left hand with PNSS 50cc @10gtts/min once Voluven is consumed. Then transfer Dopamine at the right hand 9:40pm >discontinue Dopamine >right hand with Voluven shift to ISA