Dengue fever syndrome (DFS) and dengue hemorrhagic fever (DHF) are acute febrile diseases which occur

in the tropics, can be lifethreatening, and are caused by four closely related virus serotypesof the genus Flavivirus, family Flaviviridae. It is also known as breakbone fever, since it can be extremely painful. Unlike malaria, dengue is just as prevalent in the urban districts of its range as in rural areas. Each serotype is sufficiently different that there is no cross-protection and epidemics caused by multiple serotypes (hyperendemicity) can occur. Dengue is transmitted to humans by the Aedes aegypti mosquito or more rarely the Aedes albopictus mosquito. The mosquitoes that spread dengue usually bite at dusk and dawn but may bite at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. The WHO says some 2.5 billion people, two fifths of the world's population, are now at risk from dengue and estimates that there may be 50 million cases of dengue infection worldwide every year. The disease is now endemic in more than 100 countries. As of August 2010, there where 70,000 cases reported in the Philippines by the Department of Health and 501 reported deaths.

This case presentation aims to identify and determine the problems and needs of the patient with admitting diagnosis of dengue. We also intends to help patient to promote health and understand such conditions through the application of nursing skills.

We relate this case to Florence Nightingales Environmental Theory because proper management of stored water and clean environment avoid insects and mosquitoes to lived at. It also prevents acquiring diseases especially dengue cases.

Biographical Data Name: Lyssa Melandru Barrinuevo Rosario Age: 2 years old Address: B 841-A Chrysanthemum St. Camella Homes Classic Don Bosco, Paraaque City Date of Birth: February 02, 2008 Gender: Female Status: Single Occupation: NONE Date of Admission: September 09, 2010 at 8:53pm. Attending Physician: Dr. Rodel Fontanilla Emergency Contact Person: Her Father, Daniel Ian Del Rosario

Chief Complaint Upon Admission, the client complained of fever and cough. History of Present Illness Four days prior to admission, the client is having a fever and also an unproductive cough. Past Health History The client has no any history of surgical procedures. Her past illnesses are just fever, cough and colds. Family Health History The clients mother has an asthma. Social Health History The client is the only child of Mr. Daniel Ian Del Rosario and Mrs. Mary Carla Del Rosario. The patient is a Roman Catholic.

The client completed all the vaccines like BCG given at birth, DPT 1, 2 and 3, OPV 1, 2 and 3, Hep B 1, 2 and 3 and MMR given at 11th month.

When the client has a fever, her father gave her Tempra. When she has cough, she was given Lagundi.

It is a presumptive identification of unrecognized disease or defect. It is used to determine also if the childs development is within normal. The four sectors of MMDST determine: Personal- Social, it determines if the child is playing or getting along with the people. Fine- Motor Adaptive, it determines if the child is able to see things as well as able to pick or touch things. Language, it determines if the child is able to speak. And Gross-Motor determines if the child is able to do such activities. And the client passed all of this Four Sector Test.

Blood Whole blood has two components: (1) blood plasma, a watery liquid matrix that contains dissolved substances, and (2) formed elements, which are cells and cell fragments. Blood is about 45% formed elements and 55% plasma. Normally more than 99% of the formed elements are redcolored red blood cells. Pale colorless white blood cells and platelets occupy less than 1% of total blood volume.

Substances in Blood Plasma Constituent Water (91.5%) Distribution Liquid portion of blood. Acts as solvent and suspending medium for components of blood; absorbs, transports and releases heat. Exert colloid osmotic pressure, which helps maintain water balance between blood and tissues and regulates blood volume. Smallest and most numerous plasma proteins; produced by liver. Function as transport proteins for several steroid hormones and for fatty acids. Produced by liver and by plasma cells, which develop from B lymphocytes. Antibodies help attack viruses and bacteria. Alpha and beta globulins transport iron, lipids and fat-soluble vitamins. Produced by liver. Plays essential role in blood clotting.

Proteins (7.0%)

Albumins

Globulins

Fibrinogen

Formed Elements in Blood Name Red Blood Cells Number 4.8million/2L (F) 5.4million/2L (M) Characteristics 7-82m diameter; biconcave discs, without a nucleus; live for about 120 days Most live for a few hours to a few days 10 122m diameter; nucleus has 2-5 Lobes connected by thin strands of chromatin; cytoplasm has very fine, pale lilac. Functions Hemoglobin within RBCs transports most of the oxygen and part of the carbon dioxide in the blood Combat pathogens and other foreign substances that enter the body Phagocytosis. Destruction of bacteria with lysozyme, defenses, and strong oxidants, such as super oxide anion, hydrogen peroxide, and hypochlorite anion Combat the effects of histamine in allergic reactions, phagocytes antigen antibody complexes, and destroy certain parasitic worms Liberate heparin, histamine and serotonin in allergic reactions that intensify the overall inflammatory response

White Blood Cellds

5000 10,000/2L

Neutrophils

60-70% of all WBCs

Eosinophils

2-4% of all WBCs

10-122m diameter; nucleus has 2-3lobes; large red- orange granules fill the cytoplasm 8-102m diameter; nucleus has 2 lobes; large cytoplasm granules appear deep blue-purple

Basophils

0.5-1% of all WBCs

Lymphocytes

20-25% of all WBCs

Small lymphocytes are 6-92m in diameter; large lymphocytes are 10-14 2m in diameter; nucleus is round or slightly indented; cytoplasm forms a rim around the nucleus that looks sky blue; the larger the cell, the more cytoplasm is visible

Mediate immune responses, including antigen-antibody reactions. B cells develop into plasma cells, which secrete antibodies. T cells attach invading viruses, cancer cells and transplanted tissue cells. Natural killer cells attack a wide variety of infectious microbes and certain spontaneously arising tumor cells. Phagocytosis (after transforming into fixed or wandering macrophages)

Monocytes

3-8% of all WBCs

12-202m diameter; nucleus is kidney shaped or horseshoe shaped; cytoplasm is blue-gray and has foamy Appearance 2-42m diameter cell fragments that live for 5-9 days; contain many vesicles but no Nucleus

Platelets

150,000400,000/2L

Form platelet plug in homeostasis; release chemicals that promote vascular spasm and blood clotting

Bite of a aedes mosquito carrying a flavivirus

Mosquito inject the virus to the victims skin

Virus enters the blood stream

Infects cells and generate cellular response

Initiate immune response (stimulates release of cytokines)

Cytokines destroy cell membrane and cell wall When treated early with doctor prescribed medication and manage to prevent the appearance of the other symptoms

When illness became severe Damage cells due to both cytokines and virus

IVFs and electrolyte replacements and precaution

Fluid shift from ICF - ECF

Manifest evanescent rashes

Patient recovers

Bloody vomitus, urine and stool Circulatory collapsed and Shock

Rashes in several areas of the body

DEATH

Pattern Health Perception and Health Management Nutirtion and Metabolism

Before Perceives that she is healthy Preferred rice and fish

During Perceives that she is not that healthy for having a dengue She preffered more rice and fish

Analysis Clients problem at her health status Client may have a nutritional imbalance due to inconsistent food intake Client have a probelm on her elimination

Elimination

Client have a regular and routinely bowel movement Client has no claims of difficulty in learning and percepting different sensations and have no any vision of hearing problem Sleeps normally and continuously for about 8 to 10 hours Client perceived her emotions according to her feelings and attitudes about herself

Experienced diarrhea at first day of her hospitalization and now, she is constipated Client has no claims of difficulty in learning and percepting different sensations and have no any vision of hearing problem Sleeps normally and continuously for about 8 to 10 hours Client perceived her emotions according to her feelings and attitudes about herself

Cognitive and Sensory

Clients level of cognition and perception are normal

Sleep and Rest

There is no any deprivation on her sleeping pattern Client has no any deprivation in this pattern

Self Perception and Self Concept

Role and Relationship

Has a strong bonding with his family and has no disturbances in her roles and relationship The patient identify herself according to her orientation and her knowledge about her sexuality Client has no any factor to be stressed

Has a strong bonding with his family and has no disturbances in her roles and relationship The patient identify herself according to her orientation and her knowledge about her sexuality The client is stressed because of her hospitalization Client is a Roman Catholic and go to church every sundays. Her father oriented her according to their beliefs

Good family ties will promote support for recovery and gives comfort and feeling of belongingness The client knows how could she identify which group her sexual belong The client is not comfortable on her health status that trigger stress to her Good Spiritual ties that help her to have a faster recovery and spiritually growing that improve ties between her ans God

Sexuality and Reproductive

Coping and Stress

Vakues and Belief

Client is a Roman Catholic and go to church every sundays. Her father oriented her according to their beliefs

Parts Head and Skull

Normal proportional to the size of the body, round, with prominences in the frontal area anteriorly & the occipital area posteriorly, symmetrical in all planes, gently Curved scalp is white, clean, free from masses, lumps, nits, dandruff & lesions, with no areas of tenderness upon palpation; hair is black, evenly distributed & covers the whole scalp, thick & shiny oblong shaped, symmetrical, smooth & no involuntary muscle movements

Findings proportional to the size of the body, round, with prominences in the frontal area anteriorly & the occipital area posteriorly, symmetrical in all planes, gently curved scalp is white, presence of wound, no masses, lumps, nits & dandruff, with no areas of tenderness upon palpation; hair is black, evenly distributed & covers the whole scalp, thick & shiny oblong shaped, symmetrical, smooth & no involuntary muscle movements

Analysis NORMAL

Scalp and Hair

Due to itching of scalp

Face

NORMAL

Eyes and Vision

eyes are parallel & evenly placed, symmetrical, non protruding, with scant amount of secretions, both eyes black & clear; sclera is white & clear; eyebrows are black, symmetrical, thick, can raise both symmetrically & without difficulty, evenly distributed & parallel with each other; eyelashes are evenly distributed & turned outward; upper eyelids cover a small portion of the iris, cornea & the sclera when the eyes are open, when the eyes are closed the lids meet completely, symmetrical & the color is the same as the surrounding skin; lid margins are clear, without scaling or secretions; lower palpebral conjunctiva are shiny, moist, transparent & salmon pink in color; iris are proportional to the size of the eye, round & symmetrical; pupils are from pinpoint to almost the size of the iris, round, symmetrical, constricts with increasing light & accommodation; able to move eyes in full range of direction nose is in midline, symmetrical, patent; internal nares are clean, dark pink with few cilia

eyes are parallel & evenly placed, symmetrical, non protruding, with scant amount of secretions, both eyes black & clear; sclera is white & clear; eyebrows are black, symmetrical, thick, can raise both symmetrically & without difficulty, evenly distributed & parallel with each other; eyelashes are evenly distributed & turned outward; upper eyelids cover a small portion of the iris, cornea & the sclera when the eyes are open, when the eyes are closed the lids meet completely, symmetrical & the color is the same as the surrounding skin; lid margins are clear, without scaling or secretions; lower palpebral conjunctiva are shiny, moist, transparent & salmon pink in color; iris are proportional to the size of the eye, round & symmetrical; pupils are from pinpoint to almost the size of the iris, round, symmetrical, constricts with increasing light & accommodation; able to move eyes in full range of direction nose is in midline, symmetrical, patent; internal nares are clean, dark pink with few cilia

NORMAL

Nose

NIRMAL

Ears and Hearing

parallel, symmetrical, proportional to the size of the head, bean-shaped, helix is in line with the outer canthus of the eye, skin is the same color as the surrounding area & clean; ear canal is pinkish, clean, with scant amount of cerumen & a few cilia; able to hear whisper spoken 2 feet away lips are pinkish, symmetrical, lip margin is well defined, smooth & moist; gums are pinkish, smooth, moist, no swelling, no retraction, no discharge; 32 teeth are present, aligned, with no dental caries; tongue is pinkish, slightly rough on top, smooth along the lateral margins, moist, shiny & freely movable; cheeks are pinkish, moist & smooth; frenulum is in midline, straight & thin; soft palate is pinkish, smooth & moist; hard palate is slightly pinkish; uvula is at the center, symmetrical & freely movable

parallel, symmetrical, proportional to the size of the head, bean-shaped, helix is in line with the outer canthus of the eye, skin is the same color as the surrounding area & clean; ear canal is pinkish, clean, with scant amount of cerumen & a few cilia; able to hear whisper spoken 2 feet away right ear lips are pinkish, symmetrical, lip margin is cracked & dry lips; gums are pinkish, smooth, moist, no swelling, no retraction, no discharge; 32 teeth are present, aligned, with no dental caries; tongue is pinkish, slightly rough on top, smooth along the lateral margins, moist, shiny & freely movable; cheeks are pinkish, moist & smooth; frenulum is in midline, straight & thin; soft palate is pinkish, smooth & moist; hard palate is slightly pinkish; uvula is at the center, symmetrical & freely movable

NORMAL

Mouth and Lips

Sign of Dehydration

Neck

proportional to the size of the body & head, symmetrical & straight, no palpable lumps, masses or areas of tenderness chest contour is symmetrical, spine is straight, no lumps, no masses, no tender areas, with clear breath sounds abdominal skin is unblemished, no scars, color is uniform with the body color, abdomen is rounded with symmetric movements caused by respiration; umbilicus is concave

proportional to the size of the body & head, symmetrical & straight, no palpable lumps, masses or areas of tenderness chest contour is symmetrical, spine is straight, no lumps, no masses, no tender areas, with clear breath sounds abdominal skin is unblemished, no scars, color is uniform with the body color, abdomen is rounded with symmetric movements caused by respiration; umbilicus is concave

NORMAL

Thorax and Lungs

NORMAL

Abdomen

NORMAL

Upper Extremities

symmetrical, with visible veins, fine hair evenly distributed, warm, dry & elastic upon palpation, with area of tenderness on the left arm; palms are pinkish, warm, soft & elastic; nails are transparent, smooth & convex with light pink nail beds & white translucent tips; 5 fingers in each hand; both shoulders, arms, elbows, hands & wrists can be moved in different range of motion with relative ease skin is smooth, fine hair is evenly distributed, absence of varicose veins, muscles symmetrical, length symmetrical, 5 toes in each foot, sole & dorsal surface is smooth with pink nail beds & white translucent tips; both legs, knees, ankles, & toes can be moved in different range of motion with relative ease; scar on both patellar

symmetrical, with visible veins, fine hair evenly distributed, warm, dry & elastic upon palpation, with area of tenderness on the left arm; palms are pinkish, warm, soft & elastic; nails are transparent, smooth & convex with light pink nail beds & white translucent tips; 5 fingers in each hand; both shoulders, arms, elbows, hands & wrists can be moved in different range of motion with relative ease skin is smooth, fine hair is evenly distributed, absence of varicose veins, muscles symmetrical, length symmetrical, 5 toes in each foot, sole & dorsal surface is smooth with pink nail beds & white translucent tips; both legs, knees, ankles, & toes can be moved in different range of motion with relative ease; scar on both patellar

NORMAL

Lower Extremities

NORMAL

TEST Red Blood Cells Hemoglobin Hematocrit White Blood Cells

NORMAL 3.9 5.3 110 160 0.31 0.43 5 15.5 4.21 110 0.37 4.4

FINDINGS

ANALYSIS NORMAL NORMAL NORMAL Infection of the body by the DFS strain causes in stimulation of the immune system to combat the disease causing decreased levels of WBC count in the blood DFS can cause thrombocytopenia by direct infection of bone marrow megakaryocytes as well as immunological shortened platelet survival..

Platelet Count

200 400

152

Name of the Drug Paracetamol Syrup

Dosage 120mg/5ml 5ml every 4 hours PRN for temp > 37.8C

Mechanism of actions Inhibition of cyclooxygen ase (COX), While it has analgesic and antipyretic properties comparable to those of aspirin or other NSAIDs

Indications relief of fevers, aches and pains and relieve pain in mild arthritis but has no effect on the underlying inflammation , redness, and swelling of the joint

Contraindica tions Should not be used in hypersensitivi ty to the preparation and in severe liver diseases

Adverse Effect gastrointestin al problems, allergic skin reactions, Blood dyscrasia, nephropathy , like drug combination s containing phenacetin, acute liver failure, hepatotoxicit y Burning, stinging or pain Rash, nausea, erythema, dry skin, tenderness and swelling.

Nursing Alert Use liquid form for children and patients with difficulty in swallowing In children, dont exceed five doses in 24 hours

Mupirocin (Bactroban Ointment)

Apply 3x a day

Prevent skin lesions

Indicated for the topical treatment of impetigo due to: Staphylococ cus aureus and Streptococc us pyogenes.

Contraindica ted in individuals with a history of sensitivity reactions to any of its components.

Check for any reactions of the skin toward the applied ointment

Augmentin

312mg/5ml 4ml every 8 hours

To reduce the developmen t of drugresistant bacteria and maintain the effectiveness of antibacterial drugs, should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria

Indicated in the treatment of infections caused by susceptible strains of the designated organisms in the conditions (UTI, LRTI, Otitis Media, Sinusitis, and skin infections)

Contraindica ted in patients with a history of allergic reactions to any penicillin.

Diarrhea or loose stools, nausea and vomiting, skin rashes, urticaria, and vaginitis.

Contraindica ted in patients with a previous history of cholestatic jaundice/he patic dysfunction.

Assess the client if she is allergic in Penicillin and prepare medications for resulting any adverse reaction due to allergy occur.

Dulcolax Pediatric Suppository

Once a day

To Stimulate the bowel Movement

For the treatment of occasional constipation.

In patients with ileus, intestinal obstruction, acute surgical abdominal conditions

Rarely, abdominal discomfort and diarrhea have been reported.

Check for any abdominal discomfort or report of diarrheal

Cues Subjective: Ang anak ko ilang araw na hindi dumudumi. As verbalized by the clients father. Objective: Abdominal pain, urgency, and cramping. Altered bowel sounds

Diagnosis Constipation related to decreased dietary intake

Expected Outcome STG: After 8 hours of nursing interventions, the patient will establish or return to normal patterns of bowel functioning. LTG: After 1-2 days of nursing intervention, the clients mother will verbalize ways to avoid constipation of her child.

Nursing Intervention Independent: - Determine stool color, consistency, frequency, and amount.

Rationale

Evaluation Fully Met -the patients bowel movement return to its normal pattern.

-Assists in identifying causative or contributing factors and appropriate interventions. - Bowel sounds are generally decreased in constipation. - Assists in improving stool consistency.

- Auscultate bowel sounds.

- Encourage fluid intake of 25003000 ml/day within cardiac tolerance.

- Recommend avoiding gas forming foods.

- Assist in perinial skin condition frequently, noting changes or beginning breakdown.

- Decrease gastric distress and abdominal distension.

- Prevents skin excoriation and breakdown.

- Discuss use of stool softeners, mild stimulants, bulk-forming laxatives, or enemas as indicated. Monitor effectiveness. - Encourage to eat high-fiber rich foods. Collaborative: - Consult with dietitian to provide wellbalanced diet high in fiber and bulk.

- Facilitates defecation when constipation is present.

- To enhance easy defecation. - Fiber resists enzymatic digestion and absorbs liquids in its passage along the intestinal tract and thereby produces bulk, which acts as a stimulant to defecation. -It helps in stimulation or increase the frequency of bowel evacuation

Dependent: - Administration of laxatives.

Cues Objective: Dry and cracked lips. RR: 38 Temp: 38.6C PR: 130

Diagnosis Fluid Volume Deficit related to failure of regulatory mechanisms

Expected Outcome STG: Within 8 hours, patient will maintain adequate fluid volume. LTG: After 1-2 days of nursing intervention the client will not show any signs of dehydration

Nursing Intervention Independent: -Monitored vital signs; noted changes in body temperature.

Rationale -Increased HR along with decreased BP and elevated temperature, is present in conditions with fluid volume deficit. -Fluid replacement needs are based on correction of current deficits and ongoing losses. Decreased urinary output may require aggressive fluid replacement. -Relieves thirst and aids in body fluid replacement.

Evaluation Fully met: The Client maintains the adequate fluid volume

-Monitored I/O qh; obtained daily weights and compared with 24-hr I/O.

-Encouraged increase in fluid intake and consumption of foods high in fluid content. -Turned patient q2h and provided support for body prominences.

-Patients with fluid volume deficit are more at risk for skin breakdown.

-Provided skin and mouth care, massaged skin, and applied emollients as necessary.

-Regular skin and mouth care relieves dryness and discomfort. Light massage promotes circulation. Use of emollients and mild soaps promotes good hygiene and comfort without excessive drying of the skin. -Patients on IV fluid therapy may be at risk for cardiopulmonary compromise.

-Monitored IV flow rates regularly; observed for marked elevations in BP, restlessness, moist cough, dyspnea, basilar crackles, and frothy sputum. Dependent: -Administered IV fluids as ordered.

-Aggressive fluid replacement may be required to correct fluid volume deficit.

Cues Subjective: Apat na araw na maiinit ang anak ko. As verbalized by the clients father Objective: Temp.- 38.6C Flushed skin warm to touch

Diagnosis Hyperthermia related to disease process as evidence by increase body temperature greater than the normal range

Expected Outcome After 4 hours of effective nursing intervention, the patients temperature will decrease from 38.6C to its normal range. After 1-2 days of nursing intervention the clients mother will know how to prevent the occurrence of hyperthermia

Nursing Intevention INDEPENDENT *monitor core temperature every hour *note presence of sweating as body attempts to increase heat loss by evaporation.

Rationale

Evaluation Fully Met: The client temperature decrease to 36.5

*temperature of 38.9-41.1 C suggest acute infectious disease process. *Evaporation is decreased by environmental factors of high humidity and high ambient temperature as well as body factors producing loss of ability to sweat. *to support circulating volume and tissue perfusion. *to reduce metabolic demands/oxygen consumption.

*increase oral fluid intake

*promote bed rest, encourage relaxation skills and diversional activities.

*provide TSB as needed *promote surface cooling, loosen clothing and cool environment *Review specific risk factors/causes, signs and symptoms with the interventions required

*heat is loss by evaporation and conduction. *heat is loss by convection, radiation and conduction. *to promote wellness.

DEPENDENT *Administer medications as indicated to treat underlying cause, such as: -Paracetamol
COLLABORATIVE *administer replacement fluids and electrolytes

*to decrease the body temperature

*to treat underlying Condition

Medications: Instruct the patient to take her medicines as prescribed. Exercise: teach the patient to make or to conduct exercises everyday like walking. Treatment: Follow the ordered treatment of the doctor Health Teaching: Teach the client to maintain a clean environment to avoid viral infections OPD Follow-up: Instruct the client to come back for her follow-up check up. Diet: DAT and increase fluid intake