I.

INTRODUCTION

Dengue is a mosquito-borne infection which in recent years has

become a major international public health concern. Dengue is found in
tropical and sub-tropical regions around the world, predominantly in urban
and semi-urban areas.

Dengue haemorrhagic fever (DHF), a potentially lethal complication,

was first recognized in the 1950s during the dengue epidemics in the
Philippines and Thailand. By 1970 nine countries had experienced epidemic
DHF and now, the number has increased more than fourfold and continues to
rise. Today emerging DHF cases are causing increased dengue epidemics in
the Americas, and in Asia, where all four dengue viruses are endemic; DHF
has become a leading cause of hospitalization and death among children in
several countries.

There are four distinct, but closely related, viruses that cause dengue
(1, 2, 3 or 4) of a virus from genus Flavivirus. Recovery from infection by one
provides lifelong immunity against that serotype but confers only partial and
transient protection against subsequent infection by the other three. There is
good evidence that sequential infection increases the risk of more serious
disease resulting in DHF.

Anyone who is bitten by an infected mosquito can get dengue fever.

Risk factors for dengue hemorrhagic fever include a person's age and
immune status, as well as the type of infecting virus.

Dengue fever usually starts suddenly with a high fever, rash, severe
headache, pain behind the eyes, and muscle and joint pain. The severity of
the joint pain has given dengue the name "breakbone fever." Nausea,
vomiting, and loss of appetite are common. A rash usually appears 3 to 4
days after the start of the fever. The illness can last up to 10 days, but
complete recovery can take as long as a month.
 Most dengue infections result in relatively mild illness, but some can
progress to dengue hemorrhagic fever. With dengue hemorrhagic fever, the
blood vessels start to leak and cause bleeding from the nose, mouth, and
gums. Bruising can be a sign of bleeding inside the body. Without prompt
treatment, the blood vessels can collapse, causing shock (dengue shock
syndrome). Dengue hemorrhagic fever is fatal in about 5 percent of cases,
mostly among children and young adults.

The spread of dengue is attributed to expanding geographic

distribution of the four dengue viruses and of their mosquito vectors, the
most important of which is the predominantly urban species Aedes aegypti. A
rapid rise in urban populations is bringing ever greater numbers of people
into contact with this vector, especially in areas that are favourable for
mosquito breeding, e.g. where household water storage is common and
where solid waste disposal services are inadequate.

OBJECTIVES

STUDENT NURSE-CENTERED

Short-term objectives:

After 1 – 2 days of Nursing Interventions, the student nurses will be able

to:

 Identify a patient for their case study

 Introduce themselves and state their purposes to the patient
 Establish rapport with the patient
 Gather the following data:
- demographic data
- history of past and present illness
 Perform thorough physical assessment
  Review and monitor diagnostic and laboratory results
 Actively participate with the different medical management for the
patient and reinforce the teachings the physician has been made
 Apply independent, interdependent and dependent nursing
responsibilities in every medical management
 Monitor and document the patient’s response to the disease process

Long-term objectives:

After 3 – 4 days of Nursing Interventions, the student nurses will be able

to:

 Identify modifiable and non-modifiable factors that may directly or

indirectly cause the disease condition
 Review the pathogenesis of the disease condition and formulate
patient-centered pathophysiology
 Review the signs and symptoms of the disease condition with rationale
and identify specific signs and symptoms manifested by the patient.
 Relate the assessed pertinent data, diagnostic and laboratory results
and abnormal findings of the patient to the disease process itself in
order to give a clear picture of the disease condition
 Identify nursing diagnosis from the collected data, formulate nursing
care plans, and perform nursing interventions and evaluation.
 Provide health teachings to each medical management received by
the patient
 Do actual SOAPIEs

PATIENT-CENTERED

Short-term objectives:

After 1 – 2 days of Nursing Interventions, the patient will be able to:

 Acknowledge the presence of student nurses as part of the health care

team responsible in taking care of his condition
 Develop trusting relationship with the student nurses
  Actively participate in every medical and nursing management
prescribed
 Participate during assessment and interview
 Develop good communication during the interview
 Ask and show interest during the course of nursing process

Long-term objectives:
After 3 – 4 days of Nursing Interventions, the patient will be able to:

 Understand how the disease came about/occurred

 Adhere with the health teachings given by the student nurses for each
medical and nursing management
 Comply with the treatment regimen prescribed
 Identify measures to prevent complications from the disease
 Maintain trusting relationship with the student nurses during the whole
course of treatment to gain strong compliance and attain optimum
level of functioning.

A. Current Trends about the disease condition

Development of Dengue Vaccine

By

Yuri Pervikov*

Department of Vaccines and Biologicals, World Health Organization, 1211 Geneva 27, Switzerland

Abstract

The dengue viruses are estimated to cause several hundred thousand

cases of dengue fever, dengue haemorrhagic fever and dengue shock
syndrome annually. Attempts to prevent the infection focus on the
development of a vaccine that would protect against all four serotypes of
the dengue virus. Various biotechnological approaches are being explored,
including the use of live attenuated or inactivated viruses, infectious clone-
derived vaccines, immunogens vectored by various recombinant systems,
subunit immunogens and nucleic acid vaccine. Three candidate vaccines
are undergoing clinical evaluation and several are at the stage of pre-
clinical evaluation. A WHO steering committee is conducting activities
aimed at accelerating the development of vaccines against dengue and
Japanese encephalitis.

Key words: Dengue vaccine, clinical evaluation, preclinical stage

Introduction

Dengue viruses are the most widespread arthropod-borne viruses. They are members of the
flaviviridae family, which includes more then 70 related but distinct viruses. Among these are
important aetiological agents such as those of yellow fever (YF), Japanese encephalitis (JE),
West Nile encephalitis and tick-borne encephalitis. Dengue is one of the most important
tropical infectious diseases. It is estimated that there are some 100 million cases of dengue
fever, 500 000 cases of dengue haemorrhagic fever (DHF) and 25 000 deaths attributable to
dengue annually(1). In recent decades the transmission of dengue viruses has intensified in
many countries and the disease has extended its geographical range to previously unaffected
areas of the South-East Asia Region, the Western Pacific Region and the Region of the
Americas of the World Health Organization. In the past, the African Region and the Eastern
Mediterranean Region were considered to have low incidences of dengue, but there was an
upsurge of the disease in these regions during the early 1990s. Dengue has grown
dramatically as a health, environmental and economic problem, now occurring in most
countries. More than half the Member States of the United Nations, with a population of some
2500 million, are at risk.

Dengue viruses are classified antigenically into four serotypes. Infection with one serotype
results in lifelong immunity to it but there is no cross-protection against the others. Persons
living in areas of endemicity can be infected with two, three and, probably, four dengue
serotypes during their lifetime. Infection with any serotype can produce clinical illness,
ranging from a non-specific febrile syndrome to severe and fatal DHF/dengue shock
syndrome. An immunopathological response following secondary infection of humans with a
heterologous serotype of dengue virus can be a risk factor for the more severe forms of the
disease. This was recently confirmed in Cuba, where an 18-year interval between a dengue
virus type 1 outbreak in 1977/1978 and a dengue virus type 2 outbreak in 1997 provided an
opportunity to evaluate risk factors(2). All patients with severe forms of dengue, including
cases of DHF and deaths, were born before the dengue virus type 1 epidemic, and nearly all
experienced the secondary dengue virus infection. In contrast, almost all those who sero-
converted without illness experienced the primary dengue virus infection. These observations
could have implications for the development of a dengue vaccine because they suggest that a
safe vaccine should be polyvalent to avoid inducing monotype-enhancing immune responses
that may lead to severe manifestations of the disease.

No effective vaccine is available. Research into dengue vaccines focuses on the use of live
attenuated or inactivated vaccines, infectious clone-derived vaccines, immunogens vectored
by various recombinant systems, subunit immunogens, and nucleic acid vaccines.

Tetravalent live attenuated vaccine

The most advanced live attenuated tetravalent vaccine was developed in Mahidol University,
Thailand, with the support of WHO's South-East Asia Regional Office. Attenuated viruses of all
four serotypes were developed by serial passage of wild-type viruses in primary dog kidney
(PDK) cells or other cell types(3). After intensive and stringent laboratory studies, including
evaluation in animal models, the vaccine underwent clinical trials in Thailand in mono-, di-,
tri- and tetravalent formats, which proved safe and immunogenic in adults and children. The
vaccine proceeded to commercial development by agreement with Aventis Pasteur. A
randomized, controlled, double-blind study was carried out to determine the safety and
immunogenicity of batches of the vaccine produced by this company(4). All formulations were
safe and tolerated in humans. Vaccines immunized with tetravalent vaccine gave multivalent
antibody responses, the highest antibody titres being against dengue virus type 3. A phase 1
clinical trial of Aventis Pasteur vaccine was recently completed in Thailand. After two doses,
seroconversion to all four serotypes was demonstrated in most vaccinated volunteers and
antiviral activity remained quite stable for at least a year. Various reformulations of the
tetravalent vaccine are being evaluated in an attempt to obtain a similar immune response to
each serotype. Vaccine strains developed at MahidolUniversity are characterized by lower
infection, dissemination rates and transmissibility in Aedes aegypti mosquitoes than those of
the parent viruses(5). Moreover, the phenotypes of the vaccine strains were stable and
unchanged by passage in humans and mosquitoes.

Serial passages of dengue viruses in PDK cells were used for the development of dengue
vaccine at the Walter Reed Army Institute of Research (WRAIR) in the USA. All four
monovalent formulations elicited seroconversion in humans. The vaccine was well-tolerated,
caused no clinically serious adverse events and induced the production of neutralizing
antibodies to all four serotypes. Tetravalent formulations were prepared and evaluated in a
monkey model. Challenge studies in rhesus monkeys demonstrated that most animals
seroconverted after two doses of the vaccine. After virus challenge, viremia was measurable
in 4 of 20 monkeys. In pilot studies in humans, three doses of tetravalent vaccine induced
50% and higher seroconversion to all four dengue serotypes. The dissemination rates of
WRAIR vaccine viruses in mosquitoes were low and it is unlikely that these viruses would be
transmitted under natural conditions(6). The next stages of the clinical trials are in progress.

Chimeric vaccine

Several research groups are successfully exploring infectious clone technology for the
development of a dengue vaccine. The ChimeriVaxTM system, originally developed to
construct JE vaccine, has now been applied to dengue viruses by Acambis in the USA. A
chimeric YF-dengue type 2 virus (D2) was prepared, using a recombinant cDNA infectious
clone of a YF vaccine strain (YF17D) as a backbone, into which the premembrane (PRM) and
envelope (E) genes of dengue 2 virus were inserted(7). YF vaccine was selected as a backbone
because of its excellent safety record during a long period of practical use. All monkeys
vaccinated with ChimeriVax-D2 virus developed neutralizing antibodies and were protected
against challenge with a wild-type dengue-2 virus. The high replication efficiency, attenuation
phenotype in animal models, immunogenicity and protective efficacy, and genomic stability of
ChimeriVax-D2 justify it as a novel candidate vaccine for evaluation in humans. YF/dengue
viruses for three other serotypes have been constructed and are undergoing laboratory
analysis and evaluation in animal models.
Another approach is based on the use of a dengue type 4 mutant containing a deletion in
non-coding regions as a genetic background for the construction of a dengue chimeric
vaccine(8). Viruses with deletion mutations are genetically more stable than the ones with
point mutations and are less likely to revert to the genotype of the parent virus when
propagated in vaccinees. On the basis of laboratory tests and work with a monkey model,
some deletion mutants were defined as attenuated viruses. Phase 1 clinical trials of a 3'
deletion mutant were carried out in adult humans. The results indicated that this dengue 4
deletion mutant was safe and immunogenic. It is planned to use this attenuated virus as the
backbone for the construction of chimeric dengue viruses of serotypes 1, 2 and 3. The
ultimate aim is to develop a tetravalent vaccine.

Work at the Centers for Disease Control and Prevention in the USA showed that attenuation
markers of dengue 2 vaccine strain PDK-53 were encoded by genetic loci outside the
structural gene region(9). On this basis, chimeric dengue type 2/type 1 viruses were
constructed which contained the non-structural genes of PDK-53 and structural genes of the
dengue 1 strain(10). Chimeric virus retained the attenuation in vivo and in vitro markers and
was immunogenic in mice, inducing the production of neutralizing antibodies against dengue
1. It is considered as a potential dengue 1 candidate vaccine. The results also suggest that
the infectious clones from the PDK-53 vaccine are promising attenuated vectors for the
development of chimeric flavivirus vaccines.

DNA vaccines

A candidate DNA vaccine expressing dengue virus type 1 PrM and E proteins was developed
and used for the immunization of different kinds of monkeys(11,12). The candidate vaccine
induced the production of virus-neutralizing antibodies and gave partial protection against
challenge with homologous dengue virus. Intramuscular immunization of rhesus macaques
was more immunogenic than intradermal immunization. Another study focused on the
construction of a dengue vaccine containing PrM and E genes of the Guinea C strain of
dengue type 2 virus(13). In immunized mice the candidate vaccine induced neutralizing
antibody production and strong anamnestic responses to challenge. Further extensive
preclinical and clinical trials are required before a decision can be made on the acceptability
of DNA vaccine for practical use.

Inactivated and subunit vaccines

The success of inactivated flavivirus vaccines against JE in Japan and tick-borne encephalitis
in Austria and Russia led to attempts to develop a killed dengue vaccine. However, early work
in this area was unsuccessful because of difficulties in growing high titres of dengue virus in
cell lines. It was recently shown that flaviviruses can grow to high titres in Vero cells(14).
Dengue virus type 2 was grown in Vero cells and, after inactivation, purification and
concentration, was used for the immunization of laboratory animals(15). The experimental
vaccine induced the production of a protective level of antibodies in monkeys. This approach
will probably allow the development of an effective inactivated dengue vaccine.

Recombinant DNA techniques provided the possibility of cloning specific genes encoding for
protective antigens and of expressing them in other host cells, including E.coli, yeast and
insect cell systems. This technology has been used by several researchers for the
development of subunit vaccines. Recombinant E protein of dengue 2 virus, produced in a
baculovirus vector system, induced neutralizing antibody production and partial protection of
immunized monkeys(16). Products from Drosophila cells appeared to be promising in the early
stages of testing in animals(15). Further efforts are required to increase the immunogenicity of
subunit vaccines by incorporating them into adjuvants or other systems for stimulating
immune responses.
Vaccinia virus as vector for dengue vaccine

The use of genetically-modified vaccinia virus as a vector for genes encoding flavivirus
vaccine antigen could have broad application for the genetic engineering of viral vaccine.
Modified vaccinia Ankara (MVA) vector with a restricted host range was developed for the
construction of recombinants(17). The safety of this vector was demonstrated in a large
number of volunteers. MVA and recombinants derived from this virus do not replicate
efficiently in human and most other mammalian cells, and this character is genetically stable.
Monkeys repeatedly immunized with MVA recombinant expressing dengue 2 E protein have
virus-neutralizing antibodies and are fully protected against challenge with homotypic dengue
virus(18). Work is planned on constructing MVA recombinants expressing immunogenic E
protein of other dengue virus serotypes.

WHO activity in the development of dengue vaccine

WHO has designated the dengue viruses as a high-priority target for accelerated vaccine
development. This work is conducted by a steering committee on dengue and JE vaccines,
established in 1984. In the area of dengue vaccine, the main purpose of the steering
committee is to promote and facilitate the development of candidate vaccines with a view to
expediting their introduction in developing countries. This involves the evaluation of new
biotechnological approaches, active participation in clinical trials of candidate vaccines, and
the facilitation of vaccine introduction through the planning and assessment of low-cost
vaccination schedules(19). The steering committee has supported some research projects that
have led to the development of candidate vaccines now undergoing clinical evaluation.

In order to promote the evaluation of live attenuated vaccines in clinical trials, a group of
WHO experts has been developing guidelines for the safety of dengue vaccine. These
guidelines could help public health officials to make decisions about conducting dengue
vaccine trials in their countries. They could also help researchers to arrive at technical
decisions before designing trial protocols. The steering committee on dengue and JE vaccines
supports research projects aimed at standardizing immunological methods, including the
neutralization test for dengue viruses, to be used by laboratories involved in evaluating the
immunogenicity of dengue vaccine.

B. Reason for choosing the case

 The group has chosen DHF for our case study for the reason that we want
to gain more knowledge and to generate a lot of learning experience for us,
entailed with the virtue of care and patience.

With major global demographic changes that have occurred, the most
important of which have been uncontrolled are urbanization and concurrent
population growth. These demographic changes have resulted in substandard
housing and inadequate water, sewer, and waste management systems, all
of which increase Aedes aegypti population densities and facilitate
transmission of Aedes aegypti-borne disease.

Because of these there is a greater need of study about the disease so

that we could give precautionary measures and possible preventions as well
as treatment necessary for it.

Furthermore, it is but our duty to provide appropriate nursing

interventions in managing the disease, quality nursing care and providing
health teachings to the patient on how to prevent further complications.

II. NURSING ASSESSMENT

1. PESONAL DATA
 Baby Deng is a 5-month-old female infant, bornin on the 20th day of
January 2007, at Hacienda Dolores Porac, Pampanga. She is the youngest
among the two siblings of Mr. and Mrs. Gue. She is a natural born Filipino and
a Roman Catholic. She was rush to Ospital NIng Angeles (ONA) last January 5,
2008 with a chief complain of nose bleeding.

2. PERTINENT FAMILY HISTORY

Family Gue is an extended type of family. They are composed of three

families in one house. In these three families, Baby Dend’s Family is
composed of a father, mother and two siblings. Mrs. Gue, the mother gave
birth to her two children via normal delivery. Sister Dang, the eldest is 5
years old and Baby Deng is 5-month-old, they both get enough attention they
need because their mother is plain housewife. Mr. Gue the father is an
electrician and he earns 3000 a month, according to Mrs. Gue this earning is
just enough for their family but since they lived in Mrs. Gue’s parent, they still
need to share their earnings for paying electricity and water bills. Other
expenses will be for the food and milk for the baby. Their house is a
bungalow type of house and it is closely built to the other house, it has no
drainage system and there is presence of stagnant water due to rain.

3. PERSONAL HISTORY

When Mrs.Gue was pregnant with her first baby she experienced normal
signs and symptoms of being pregnant. She vomits every morning while on
her first trimester and was always sleepy, same as through with her second
baby. Both of her pregnancy she practiced going to the “mananawas” then
went to clinic on her 3rd trimester for her prenatal check up.

Baby Deng was breastfeed for only one week for the reason she always
vomits after she is fed. Mrs. Gue then decided to bottle-feed her baby. Baby
Deng received her vaccine on their barangay health center. She already
received BCG, OPV, DPT, and HEPA B, which mean she has complete
immunization for her age.
Growth and development:

Erik Erikson (Psychosocial Developmental)

Baby Deng is a 5-month-old and she belongs to developmental task of

trust vs. mistrust. The important event in this stage is feeding. According to
Erikson, the infant will develop a sense of trust only if the parent or caregiver
is responsive and consistent with the basic needs being meet. The need for
care and food must be met with comforting regularity. The infant must first
form a trusting relationship with the parent or caregiver; otherwise a sense of
mistrust will develop.
This behavior was observed when the mother as well as other
caregivers gave the necessity the child needs, such as food when she is
hungry and comforting the baby when crying.

Jean Piaget (Cognitive Development)

At her age she belongs to sensorimotror stage. During this stage, an
infant’s knowledge of the world is limited to their sensory perceptions and
motor activities. Behaviors are limited to simple motor responses caused by
sensory stimuli. Children utilize skills and abilities they were born with, such
as looking, sucking, grasping, and listening, to learn more about the
environment.
This was manifested by Baby Deng when the group was gathering
information from her mother. She was simply observing the people around
her.

Sigmund Freud (Psychosexual Stage of Development)

Baby Deng belongs to oral phase of Freud’s theory. In this stage the
mouth is the primary erogenous zone through which pleasure is derived. The
major conflict issue during this stage is the weaning process, during which
the child is forced to become less dependent upon caretakers. A fixation at
this stage can result in problems with dependency or aggression.
 This was observed when she was thumb sucking, she seems like she
receives gratification from what she doing.

4. History of Past Illness

Presently Baby Deng was the only one in the family who is sick. It was
her first time to be hospitalized. Her past illnesses includes mild fever, cough
and colds, which the family manages with the use of antipyretic like
paracetamol and drinking lots of water. She also had German measles.

With her immediate family members, both her sister and her mother
got German measles and allowed the illness to eventually disappear without
any intervention being done. Other members of the family occasionally
experience mild fever. The family then consults to their barangay health
center for assistance and to acquire the appropriate medicine.

Among her relatives her Grandmother on her father’s side has diabetes
and her grandfather dies because of DM. Her grandmother on the mother’s
side has hypertension. Then her auntie has allergic Rhinitis.

5. History of Present Illness

Two days prior to admission, Baby Deng experienced occasional nose

bleeding for the first day. On the second day she had severe nose bleeding.
Mrs. Gue decided to bring her child to ONA for further assessment and to
seek treatment for her child’s condition. Then physician then diagnosed Baby
Deng with Dengue Hemorrhagic Fever II.

6. PHYSICAL EXAMINATION

January 5, 2008 (Admission)

Vital Signs: T: 36.2ºC, PR: 120bpm, RR: 30 cpm
Skin: conscious, not in distress,
Head-EENT: pink palpebral conjunctiva besides sclera,
Lymph Nodes: no palpable cervical
Lungs: Chest expansion, no retractions,
Cardiovascular: no murmurs
Abdomen: abdomen is flat, w/ Normal Abdominal Breath Sounds, soft

January 07, 2008

• General Appearance
 Weight: 7.5 kg
 Waist circumference: 19 inches

• Skin
 Skin is intact, uniform in color
 Rashes observed on the left cheek
 Skin return to original position after being pinched
 Scars noted on upper and lower extremities

• Hair
 Black in color
 Straight hair
 Hair is evenly distributed all over the scalp
 Hair strands are thin and not brittle
 Scalp has no nodules, masses, tenderness and redness present

• Nails
 Dirty and untrimmed fingernails and toenails
 Capillary refill time of < 2 seconds
 No clubbing and brittleness noted
• Skull and Face
 Round normocephalic
 No lesion and nodules noted
 Face: no contusion or scars noted
 Symmetrical facial features and movements
 Client is able to smile

• Eyes and Vision

 Eyebrows: evenly distributed and aligned, no lice noted
 Eyelashes: evenly distributed and curled outward
 Eyelids: symmetrical and have smooth texture
 Bulbar conjunctiva: is transparent, smooth and shiny
 Pink palpebral conjunctiva
 No presence of nodules, lesion, swelling and discharges noted
 Sclera is White
 Eyeballs: symmetrical, aligned and do not bulge outward

• Nose and Sinuses

 External nose is properly aligned in between eyes
 Presence of cough and colds
 No deformities, discharges, lesion, and tenderness noted
 No tenderness and swelling of sinuses noted

• Ears and Hearing

 Symmetrical and aligned to the outer canthus of the ears
 No lesion and tenderness noted upon palpation
 No discharges, inflammation, nor deformities observed
 Pinna recoils back when it is folded

• Mouth
  Outer lips are uniform, no cracks
 Inner lips and buccal mucosa are pinkish in color
 Gums are pink and no bleeding is noted
 Uvula is positioned midline
 Tongue: in central position
 Pinkish in color, moist and with no lesion
 Light pink, no inflammation, no discoloration of soft and hard palate
 Pink smooth tonsils, with no discharge and no swelling upon
observation

• Neck
 Neck is symmetrical
 Neck muscles: equal in size
 No masses noted
 Undistended jugular veins
 lymph nodes: not palpable noted
 Trachea in midline of neck, spaces are equal on both sides
 Normal pulse rhythm

• Chest and Lungs

 Chest is symmetrical
 No deformities, and masses noted
 Absence of nodules and tenderness
 With rales on both lung fields

• Heart
 With normal heart rate of 100bpm
 Full pulsation
 No abnormal heart sound noted upon auscultation

• Abdomen
  Absence of scar and rash
 No tenderness and mass noted
 With tympanic sound heard upon percussion
 With audible borborygmi bowel sounds, 10 sounds per minute upon
auscultation

• Extremities
 Extremities are symmetrical and have uniform skin color
 With scars on both leg secondary to chicken pox

January 08, 2008

• Skin
 Skin is intact, uniform in color
 No wounds and lesion noted
 Skin return to original position after being pinched

• Hair
 Black in color
 straight hair
 Hair is combed
 Hair is evenly distributed all over the scalp
 Hair strands are thin and not brittle
 Scalp has no nodules, masses, tenderness

• Nails
 Dirty fingernails and toenails
 Capillary refill time of < 2 seconds
 No clubbing and brittleness noted
• Skull and Face
 Round normocephalic
 No lesion and nodules noted
 Face: no contusion or scars noted
 Symmetrical facial features and movements
 Client is able to smile,

• Eyes and Vision

 Eyebrows: evenly distributed and aligned, no lice
 Eyelashes: evenly distributed and curled outward
 Eyelids: symmetrical and have smooth texture
 Bulbar conjunctiva: is transparent, smooth and shiny
 Pink palpebral conjunctiva
 No presence of nodules, lesion, swelling and discharges noted
 Eyeballs: symmetrical, aligned and do not bulge outward

• Nose and Sinuses

 External nose is properly aligned in between eyes
 Presence of cough and colds
 No deformities, discharges, lesion, and tenderness noted
 No tenderness and swelling of sinuses noted

• Ears and Hearing

 Symmetrical and aligned to the outer canthus of the ears
 No lesion and tenderness noted upon palpation
 No discharges, inflammation, nor deformities observed
 Pinna recoils back when it is folded
 Firm and no infection noted

• Mouth
  Outer lips are uniform , no cracks
 Inner lips and buccal mucosa are pink in color
 Gums are pink and no bleeding is noted
 Uvula is positioned midline
 Tongue: in central position
 Pinkish in color, moist and with no lesion
 Light pink, no inflammation, no discoloration of soft and hard palate
 Pink smooth tonsils, with no discharge and no swelling upon
observation

• Neck
 Neck is symmetrical
 Neck muscles: equal in size
 No masses noted
 Undistended jugular veins
 lymph nodes: not palpable
 Trachea in midline of neck, spaces are equal on both sides
 Pulsation of carotid artery felt
 Symmetric pulse volume
 Normal pulse rhythm

• Chest and Lungs

 Chest is symmetric
 No deformities, and masses noted
 Absence of nodules and tenderness
 With rales on both lung fields

• Heart
 With normal heart rate of 118bpm
 Full pulsation
  No abnormal heart sound noted upon auscultation

• Abdomen
 Absence of scar and rash
 No tenderness and mass noted
 No signs of swelling
 With tympanic sound heard upon percussion
 With audible borborygmi bowel sounds, 16 sounds per minute upon
auscultation

• Extremities
 Extremities are symmetrical and have uniform skin color
 With scars on both legs secondary to chicken pox

January 09, 08
• Skin
 Skin is intact, uniform in color
 No wounds and lesion noted
 Skin return to original position after being pinched
 Absence of petechiae

• Hair
 Black in color
 Straight hair
 Hair is evenly distributed all over the scalp
 Hair strands are thin and not brittle
 Scalp has no nodules, masses, tenderness and redness present
• Nails
 Dirty fingernails and toenails
 Capillary refill time of < 2 seconds
  Pink in color nail beds
 No clubbing and brittleness noted

• Skull and Face

 Round normocephalic
 No lesion and nodules noted
 Face: no contusion or scars noted
 Symmetrical facial features and movements
 Client is able to smile

• Eyes and Vision

 Eyebrows: evenly distributed and aligned, no lice
 Eyelashes: evenly distributed and curled outward
 Eyelids: symmetrical and have smooth texture
 Bulbar conjunctiva: is transparent, smooth and shiny
 Smooth and pink palpebral conjunctiva
 No presence of nodules, lesion, redness, swelling and discharges
noted
 Eyeballs: symmetrical, aligned and do not bulge outward
 Cornea: transparent and shiny

• Nose and Sinuses

 External nose is properly aligned in between eyes
 No deformities, discharges, lesion, and tenderness noted
 Nostrils are patent
 No tenderness and swelling of sinuses noted

• Ears and Hearing

 Symmetrical and aligned to the outer canthus of the eyes
 No lesion and tenderness noted upon palpation
 No discharges, inflammation, nor deformities observed
  Pinna recoils back when it is folded
 Firm and no infection noted

• Mouth
 Outer lips are uniform, no cracks
 Inner lips and buccal mucosa are pink, moist, shiny and soft
 Gums are pink and no bleeding is noted
 Uvula is positioned midline
 Tongue: in central position
 Pinkish in color, moist and with no lesion
 Moves freely
 Light pink, no inflammation, no discoloration of soft and hard palate
 Pink smooth tonsils, with no discharge and no swelling upon
observation
 With good appetite

• Neck
 Neck is symmetrical
 Neck muscles: equal in size
 No masses noted
 Smooth coordinated head movement without discomfort
 Undistended jugular veins
 Lymph nodes: not palpable
 No swelling and tenderness noted
 Trachea in midline of neck, spaces are equal on both sides
 No presence of infection and inflammation in thyroid glands
 Pulsation of carotid artery felt
 Symmetric pulse volume
 Normal pulse rhythm
• Chest and Lungs
 Chest is symmetrical
 No deformities, and masses noted
 Absence of nodules and tenderness

• Heart
 With normal heart rate of 120bpm
 Full pulsation
 No abnormal heart sound noted upon auscultation

• Abdomen
 Absence of scar and rash
 No tenderness and mass noted
 No signs of swelling
 With tympanic sound heard upon percussion
 With audible borborygmi bowel sounds, 19sounds per minute upon
auscultation

• Extremities
 Extremities are symmetrical and have uniform skin color
 With scars on both leg secondary to chicken pox
 Absence of body weakness
Reflexes

Disappearan Actual
Reflex Description Appearance
ce Finding
Toes fan Baby Deng
upward when has positive
sole of the babinski
foot is reflex as
stroked in an evidenced by
Babinski inverted J. Birth 9 months fanning of
toes when
stroke the
foot in an
inverted J
manner.
Arching of Baby deng
trunk toward has negative
stimulated gallant reflex
side when as evidenced
infant is by absence
stroked along of arching of
Neonatal
Galant spine Birth the trunk
Period
toward
stimulated
side when
infant
stroked along
spine.
Moro Sudden Birth 4 months Baby deng
Startle outward has negative
extension of moro startle
arms with reflex as
midline evidenced by
returns when absence of
 startled by sudden
loud noise or outward
rapid change extension of
in position. arms with
midline
returns when
startled by
loud noise or
rapid change
in
Grasping of Baby deng
object with has negative
fingers when palmar reflex
palm is as evidenced
touched by absence
Palmar Birth 4 months
of grasping
of object with
fingers when
palm is
touched
Inward Baby deng
flexion of has positive
toes when plantar reflex
balls of feet as evidenced
Plantar are touched Birth 12 months by inward
flexion of
toes when
balls of feet
are touched
Rooting Turning head Birth 6 months Baby deng
towards has positive
stimulated rooting reflex
side of cheek as evidenced
by turning
 head towards
stimulated
side of cheek
Initiation of Baby deng
sucking when has positive
object is sucking
placed in reflex as
Sucking mouth Birth indefinite evidenced by
sucking when
object is
placed in
mouth
Mimicking Baby deng
swimming has negative
movement swimming
when heel reflex as
horizontally evidenced by
placed in absence of
Swimming water Birth 4 months mimicking
swimming
movement
when heel
horizontally
placed in
water
Walking Making First week 12 months Baby deng
stepping and has positive
movements reappears at walking
when held 4 or 5 months reflex as
upright with evidenced by
feet touching making
a surface. stepping
movements
when held
 upright with
feet touching
a surface.
Attempting to Baby Deng
maintain has positive
head in righting
upright reflex as
position evidenced by
Righting Birth 24 months
attempting to
maintain
head in
upright
position.
7. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic/ Analysis and

Date Ordered; Indications or
Laboratory Results Normal Values Interpretation
Date Result in Purposes
Procedures of Results
Urinalysis DO: It yields a large Color: light yellow Yellow Light yellow urine
January 5, 2008 amount of indicates an
DR: information about adequate intake
January 5, 2008 possible kidney of water.
Transparency: Clear Turbidity of urine
and lower urinary
Slightly turbid is a normal
tract infections.
characteristic of
any kidney
infection.
Excessive cellular
material or
protein in the
urine causes it.
Specific gravity: 1.003-1.025 The specific
1.005 gravity of the
patient’s urine is
within normal
limit.
 pH: 6.0 4.5 – 8.0 The pH of the
patient is within
normal limit.
Albumin: Negative The albumin of
negative the patient is
normal

Nursing Responsibilities: (Urinalysis)

Before the procedure

 Check the doctor’s orders.

 Verify patient’s name in the chart with the actual patient.
 Explain that the procedure is done to detect any alteration in kidney function and the presence of infection in
the urinary tract.
 Inform the patient that there is no special diet or fasting.
 Prepare laboratory request and inform lab.
 Instruct proper hygiene and hand washing.
 Instruct patient to catch midstream urine in the container.

During the procedure

  Provide privacy

After the procedure

 Bring the specimen to the laboratory.

 Explain the importance of the said procedure that this could be a help in assessing the pt’s condition
 The day before the procedure, the pt or the pt’s SO should be notify that there would be no meals post
midnight and the day before the test
 Prepare the pt. and remind them that it is best to collect specimen at the mid urination to have a clean catch
of the specimen.
 After collecting the needed specimen, the pt. could take meals if the doctor ordered to do so.
 Document the time and procedure done.
 Obtain results and secure it to the patient’s chart.

Diagnostic/ Analysis/Interpreta
Date ordered/ Indication or
Laboratory Results Normal Values tion
Date results in purpose
Procedure
Hematology
Hemoglobin DO: January 05, The test is 135 120 – 160 gm/L Normal level
(Hgb) 2008 normally indicates no
performed as presence of
DR: January 05, part of a hydration,
2008
complete blood polycythemia and
count. anemia
Hemoglobin
serves as a
vehicle for
oxygen and
carbon dioxide
transport. To
determine
oxygen carrying
capacity of the
blood. It
evaluates the
hemoglobin
content of
erythrocytes.
0.39
Hematocrit 0.37 – 0.47 L/L
DO: January
( Hct) 5,2008 Normal level
indicates no
 DR: January presence of
5,2008 hydration,
It is routinely
polycythemia and
performed as anemia
part of a
complete blood
count. It
measures the
percentage of
RBCs in the total
blood volume. It
may also provide
idea on patient’s
fluid status

DO: January 9.8

WBC 5,2008 5 -10 x 109 /L
This a normal
DR: January
5,2008 findings

It is used to
measure WBC
DO: January counts which are 96
Platelet 5,2008 150 – 400 x
capable of
109/L
 DR: January fighting infection.
5,2008
Dysfunction or low
levels of platelets
predisposes to
To confirm visual bleeding.
estimate of
platelet and
morphology
DO: January 5, 13sec
Prothrombin 2008 control:13 sec.
time(PT) % activity :100% 11-15 seconds
DR: January 5,
2008 The patient has
normal amounts of
clotting factors VII
Determine the and X.
activity and
interaction of
factors
V,VII,X,prottombi
n and fibrinogen
used to monitor
patients taking
certain
DO: January 5, 53sec
medications as
Partial 2008 control:38sec
well as to help
thromboplastin 28 - 45 seconds.
diagnose clotting
time (PTT) DR: January 5,
disorders.
2008

The patient has

To looks at how increase PTT this
long it takes for indicate a clotting
blood to clot. It factor may be
 can help tell if
you have missing or defective
bleeding or
clotting problems

Diagnostic/ Analysis/Interpreta
Date ordered/ Indication or
Laboratory Results Normal Values tion
Date results in purpose
Procedure
Hematology

The test is 93 120 – 160 gm/L Low transport and

Hemoglobin DO: January 05,
exchange of oxygen
normally
(Hgb) 2008 to the tissues and
 performed as carbon dioxide from
the tissues
DR: January 05, part of a
2008
complete blood
count.
Hemoglobin
serves as a
vehicle for
oxygen and
carbon dioxide
transport. To
determine
oxygen carrying
capacity of the
blood. It
evaluates the
hemoglobin
content of
erythrocytes.

Hematocrit DO: January It is routinely

0.28 0.37 – 0.47 L/L Low RBC
5,2008
 ( Hct) performed as /hemoglobin to the
DR: January plasma level.
part of a
5,2008
complete blood
count. It
measures the
percentage of
RBCs in the total
blood volume. It
may also provide
idea on patient’s
fluid status

DO: January
WBC 4.3
5,2008 It is used to 5 -10 x 109 /L
measure WBC The WBC is below
DR: January normal limits. Patient
5,2008 counts which are has sign of infection
capable of
fighting
infection.

DO: January 5,
Platelet 89
2008 150 – 400 x
109/L Dysfunction or low
DR: January 5, To confirm visual levels of platelets
2008 estimate of predisposes to
 platelet and bleeding.
morphology

Diagnostic/ Analysis/Interpreta
Date ordered/ Indication or
Laboratory Results Normal Values tion
Date results in purpose
Procedure
Hematology

The test is 107 120 – 160 gm/L Low transport and

Hemoglobin DO: January 05,
exchange of oxygen
normally
(Hgb) 2008 to the tissues and
performed as carbon dioxide from
the tissues
part of a
DR: January 05,
2008 complete blood
count.
Hemoglobin
 serves as a
vehicle for
oxygen and
carbon dioxide
transport. To
determine
oxygen carrying
capacity of the
blood. It
evaluates the
hemoglobin
content of
erythrocytes.

Hematocrit It is routinely 0.32

DO: January 0.37 – 0.47 L/L Low RBC
( Hct) performed as
5,2008 /hemoglobin to the
part of a plasma level.
DR: January
complete blood
5,2008
count. It
measures the
 percentage of
RBCs in the total
blood volume. It
may also provide
idea on patient’s
fluid status

WBC 7.8
It is used to
DO: January 5 -10 x 109 /L
5,2008 measure WBC The result is within
counts which are normal limits
DR: January
5,2008 capable of
fighting
infection.

Platelet 180
DO: January 5, 150 – 400 x
2008 109/L The result is within
To confirm visual
normal limits
estimate of
DR: January 5,
platelet and
2008
morphology
Nursing Responsibilities :( Hematology)

Before the procedure:

 Check the doctor’s orders.
 Explain to the patient that small amount of blood will be drawn from her and that blood will be tested to
measure if her blood cells are within normal values and to detect some blood abnormalities such as anemia,
polycythemia or detect infections.
 Inform the client that there are no fluid restrictions or fasting.
 Inform the patient that he will experience mild pain at the site of extraction during collection.
 Ensure that the patient understands the procedure.
 Prepare laboratory request and inform laboratory.
 Inform the client of the scheduled extraction.

During the procedure:

 Provide comfort measures to decrease the client’s anxiety.
 Place the client in a comfortable position.
 Maintain aseptic technique.
 Assist medical technologist if necessary.
After the procedure:
 Instruct patient to apply slight pressure at the site of extraction for a few minutes.
 Place the patient in a comfortable position and leave his room quietly.
Document the time and procedure done. Then, obtain results and secure it in the patient’s chart. Refer
III. ANATOMY AND PHYSIOLOGY

The Blood
Blood is a specialized bodily fluid (technically
a tissue) that is composed of a liquid called blood
plasma and blood cells suspended within the
plasma. The blood cells present in blood are red
blood cells (also called RBCs or erythrocytes), white
blood cells (including both leukocytes and
lymphocytes) and platelets (also called
thrombocytes). Plasma is predominantly water
containing dissolved proteins, salts and many other
substances; and makes up about 55% of blood by
volume.

By far the most abundant cells in 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. White blood cells
help to resist infections and parasites, and platelets are important in the
clotting of blood.

Blood is circulated around the body through blood vessels by the

pumping action of the heart. 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.
Anatomically and histologically, 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.
Blood performs many important functions within the body including:

• Supply of oxygen to tissues (bound to hemoglobin which is carried in

red cells)
• Supply of nutrients such as glucose, amino acids and fatty acids
(dissolved in the blood or bound to plasma proteins)
• Removal of waste such as carbon dioxide, urea and lactic acid
• Immunological functions, including circulation of white cells, and
detection of foreign material by antibodies
• Coagulation, which is one part of the body's self-repair mechanism
• Messenger functions, including the transport of hormones and the
signalling of tissue damage
• Regulation of body pH (the normal pH of blood is in the range of 7.35 -
7.45)
• Regulation of core body temperature
Plasma
Plasma is a pale yellow fluid that consists of
about 91% water, 7% proteins; and 2% other
substances, such as ions, nutrients, gases, and
waste products. Plasma proteins include albumin,
globulins, and fibrinogen. Albumin makes up 58%
of the plasma proteins. Although the osmotic
pressure of the blood results primarily from sodium
chloride, albumin makes an important contribution.
The water balance between blood and tissues is
determined by the movement of water into and out
of the blood by osmosis. Globulins account for 38%
of the plasma proteins. Some globulins, such as antibodies and complement,
are part of the immune system. Other globulins and albumin function as
transport molecules because they bind to molecules such as hormones and
carry them in the blood throughout the body. Fibrinogen constitutes 4% of
plasma proteins and is responsible for the formation of blood clots.

Formed Elements
About 95% of the volume of the formed elements consists of red blood
cells (RBCs), or erythrocytes. The remaining 5% of the volume of the formed
elements consists of white blood cells (WBCs), or leukocytes and cell
fragments called platelets, or thrombocytes. Red blood cells are 700 times
more numerous than white blood cells and 17 times more numerous than
platelets.

Production of Formed Elements

The process of blood cell production is called hematopoiesis. In the
fetus, hematopoiesis occurs in several tissues such as the liver, thymus
gland, spleen, lymph nodes, and red bone marrow. After birth, hematopoiesis
is confined primarily to red bone marrow, but some white blood cells are
produced in the lymphatic tissue.
 All the formed elements of the blood are derived from a single
population of cells called stem cells. These stem cells differentiate to give rise
to different cell lines, each of which ends with the formation of a particular
type of formed element. The development of each cell line is regulated by
specific growth factors.

Red Blood Cells

Normal red blood cells are disk-
shaped cells with edges that are thicker
than the center of the cell. The biconcave
shape increases the surface area of the red
blood cell compared with a flat disk of the
same size. The greater surface area makes
it easier for gases to move into and out of
the red blood cell. In addition, the red blood
cell can bend or fold around its thin center;
decreasing its size and enabling it pass more easily through small blood
vessels.

During their development, red blood cells lose their nuclei and most of
their organelles. Consequently, they are unable to divide. Red blood cells live
for about 120 days in males and 110 days in females. The main component of
a red blood cell is the pigmented protein hemoglobin, which accounts for
about a third of the cell’s volume and is responsible for its red color.

Function of Red Blood Cells

The primary functions of red blood cells are to transport oxygen from
the lungs to the various tissues of the body and to assists in the transport of
carbon dioxide from the tissues to the lungs. Oxygen transport is
accomplished by hemoglobin, which consists of four protein chains and four
heme groups. Each protein, called a globin, is bound to one heme, a red-
pigmented molecule. Each heme contains one iron atom, which is necessary
for the normal function of hemoglobin. When hemoglobin is exposed to
oxygen, one oxygen molecule binds to the iron atom of each heme.
Hemoglobin that is bound to oxygen is bright red in color, whereas
hemoglobin without bound oxygen is a darker red color. Hemoglobin is
responsible for 98.5% of the oxygen transported in blood. The remaining
1.5% is transported dissolved in plasma.

Carbon Dioxide transport involves by carbonate ions, hemoglobin, and

plasma. Approximately 70% of the carbon dioxide in blood is transport in the
form of bicarbonate ions. The enzyme carbonic anhydrase, bound primarily
inside red blood cells, catalyzes a reaction that converts carbon dioxide and
water into a hydrogen ion and a bicarbonate ion.

Life History of Red Blood Cells

Under normal conditions, about 2.5 million red blood cells are
destroyed every second. Fortunately, new red blood cells are produced as
rapidly as old red blood cells are destroyed. Stem cells form proerythroblasts,
which gives rise to the red blood cell line. Red blood cells are the final cells
produced from a series of cell division. After each cell division, the newly
formed cells change and become more like a mature red blood cells. After the
final cell division, the nucleus is lost from the cell, and a completely mature
red blood cell is formed.

Low blood oxygen levels increase red blood cell production by

increasing the formation of the glycoprotein erythropoietin by the kidneys.
Erythropoietin stimulates red bone marrow to produce more red blood cells.
Thus, when oxygen levels in the blood decrease, the production of
erythropoietin increases, which increases red blood cell production. The
increased number of red blood cells increases the ability of the blood ton
transport oxygen. This mechanism returns blood oxygen levels to normal and
maintains homeostasis by increasing the delivery of oxygen to tissue.

Old, abnormal, or damaged red blood cells are removed from the blood
by macrophages located in the spleen and liver. Within the macrophage the
globin part of the molecule is broken down into amino acids that are reused
to produce other proteins. The iron released from heme is transported in the
blood to the red bone marrow and is used to produce new hemoglobin. Only
small amounts of iron are required in the daily diet because the iron is
recycled.

White Blood Cells

White blood cells or leukocytes are
spherical cells that are whitish in color because
they lack hemoglobin. They are larger than red
blood cells, and each has a nucleus although
white blood cells are component of the blood,
the blood serves primarily as a means to
transport these cells to other tissues of the
body. White blood cells can live the blood and
move by ameboid movement through the
tissues. Two functions of white blood cells are (1) to protect the body against
invading microorganisms and (2) to remove dead cells and debris from the
tissues by phagocytosis.

White blood cells are named according to their appearance in stained

preparations. Those containing large cytoplasmic granules are granulocytes,
and those with very small granules that cannot be easily seen with the light
microscope are agranulocytes.
 There are three kinds of granulocytes: neutrophils, basophils and
eosinophils and there are two kinds of agranulocytes: lymphocytes and
monocytes.

Approx.
Microscopic
Type % in Description
Appearance
humans

Neutrophils deal with defense against

Neutrophil 65%
bacterial or fungal infection and other
very small inflammatory processes
and are usually first responders to
microbial infection; their activity and
death in large numbers forms pus.
They are also known as
polymorphonuclear leukocytes and
microphages. The term microphage
arises due to the cells' active
involvement in phagocytosis. 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
faintly pink in color. Neutrophils are
very active in phagocytosing bacteria
and are present in large amount in
the pus of wounds. Unfortunately,
these cells are not able to renew their
lysosomes used in digesting microbes
and die after having phagocytosed a
 few pathogens - explaining why they
are found primarily in the pus, not in
tissue.

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
Eosinophil 4% 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.

Basophils are chiefly responsible for

allergic and antigen response by
releasing the chemical histamine
causing inflammation. The nucleus is
Basophil 1% bi- or tri-lobed, but it is hard to see
because of the number of coarse
granules which hide it.

They are characterised by their large

blue granules.
 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 to pathogens, but
after an attack, some B cells

Lymphocyt will retain the ability to produce

25%
e an antibody to serve as a
'memory' system.)
• T cells: T cells co-ordinate the
immune response and are
important in the defence
against intracellular bacteria. T
cells are able to kill virus-
infected and tumor 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 6% 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
microrganisms. Neither of these can
be dealt with effectively by the
neutrophils. Unlike neutrophils
monocytes are able to replace their
lysosomal contents and are thought to
have a much longer active life. They
have the kidney shaped nucleus and
typically agranulated. They also
possess abundant cytoplasm.

Platelets
Platelets, or thrombocytes, are minute
fragments of cells, each consisting of a small
amount of cytoplasm surrounded by cell
membrane. They are produced in the red bone
marrow from megakaryocytes, which are large
cells. Small fragments of these cells break off
and enter the blood as platelets, which play an
important role in preventing blood loss. This
prevention is accomplished in two ways: (1) The formation of platelet plugs,
which seal holes in small vessels, and (2) the formation of clots, which helps
seal off larger wounds in the vessels.

Preventing Blood Loss

 When a blood vessel is damaged, blood can leak into other tissues and
interfere with normal tissue function, or blood can be lost from the body. A
small amount of blood loss from the body can be tolerated, and new blood is
produced to replace it. If a large amount of blood is lost, death can occur.
Fortunately, when a blood vessel is damaged, vascular spasm, platelet clot
formation, and blood clotting minimize the loss of blood.

Vascular Spasm
Vascular spasm is an immediate but temporary constriction of a blood
vessel resulting from contraction of smooth muscle within the vessel. This
constriction can close small vessels completely and stop the flow of blood
through them. Nervous system reflexes and chemicals produce vascular
spasms.

Platelet Plugs
A platelet plug is an accumulation of platelets that can seal up a small
break in a blood vessel. Platelet plug formation is very important in
maintaining the integrity of the circulatory system because small tears occur
in the smaller vessels and capillaries many times each day, and platelet clot
formation quickly closes them. People who lack the normal number of
platelets tend to develop numerous small hemorrhages in their skin and
internal organs.
The formation of a platelet plug can be described as a series of steps,
but in actuality many of these steps occur at the same time. Platelet
adhesion results in platelets sticking to collagen exposed by blood vessel
damage. Most platelet adhesion is mediated through von Willebrand’s factor,
which is a protein produced and secreted by blood vessel endothelial cells.
Von Willebrand’s factor forms a bridge between collagen and platelets by
binding to platelet surface receptors and collagen. After platelets adhere to
collagen, they become activated, change shape, and release chemicals. In
the platelet release reaction, platelets release chemicals, such as ADP and
thromboxane, which activate other platelets. As platelets become activated,
they express surface receptors called fibrinogen receptors, which can bind to
fibrinogen, a plasma protein. In platelet aggregation, fibrinogen forms bridges
between the fibrinogen receptors of numerous platelets, resulting in the
formation of a platelet plug. Activated platelets also produce chemicals, such
as phospholipids, that are important for blood clotting.

Blood Clotting
Blood vessel constriction and platelet plugs alone are not sufficient to
close large tears or clots in blood vessels. When a blood vessel is severely
damaged, blood clotting, or coagulation, results in the formation of a clot. A
clot is a network of threadlike protein fibers, called fibrin that traps blood
cells, platelets, and fluid.
The formation of a blood clot depends on a number of proteins found
within plasma called clotting factors. Normally the clotting factors are
inactive and do not cause clotting. Following injury, however, the clotting
factors are activated to produce a clot. This is a complex process involving
many chemical reactions, but it can be summarized in three main stages.
1.) The chemical reactions can be started into two ways: (a) the contact
of inactivate clotting factors with exposed connective tissue can result
in their activation; (b) chemicals such as thromboplastin, released from
injured tissues can cause activation of clotting factors. After the initial
clotting factors are activated, they in turn activate other clotting
factors. A series of reactions results in which each clotting factor
activates the next in the series until the clotting factor prothrombinase
is formed.
2.) Prothrombinase acts on an inactive clotting factor called prothrombin
to convert it to its active form called thrombin.
3.) Thrombin converts the inactive clotting factor fibrinogen into its active
form, fibrin, and a threadlike protein. A cot is a network of fibrin that
traps blood cells, platelets, and fluid.

Control of Clot Formation

Without control, clotting would spread from the point of its initiation
throughout the entire circulatory system. The blood contains several
anticoagulants, which prevent clotting factor from forming clot. Antithrombin
and heparin inactivate thrombin. Without thrombin fibrinogen is not
converted to fibrin, and no clot forms. Normally there are enough
anticoagulants in the blood to prevent clot formation. At an injury site,
however, the activation of clotting factors is very rapid. Enough clotting
factors are activated so that the anticoagulants can no longer prevent a clot
from forming. Away from the injury site there are enough anticoagulants to
prevent clot formation from spreading.

If blood clots too quickly/easily then thrombosis may occur. This is

blood clotting in an unbroken blood vessel, which is dangerous and can lead
to strokes or heart-attacks. Conversely, if blood takes too long to clot
hemorrhage may occur. In this case much blood may be lost from the blood
vessels, which is also dangerous.

IV. THE PATIENT’S ILLNESS

A. Pathophysiology

a1. Schematic Diagram (Book-Centered)

 A person with dengue
Source of infection

Bitten by mosquito (aedes aegypti)

Reservoir

Bite a person without dengue

Dengue virus invade the body

As a defense mechanism, the body of the person produce antibody against

invading pathogens

Person bitten again by an infected aedes aegypti

The pre-existing heterologous dengue antibody recognizes the infecting virus

and forms an antigen-antibody complex

Bound to and internalized by immunoglobulin FC receptor on the cell

membrane of leukocytes especially macrophages

The entry of the virus into the cell of because the antibody is
the virus is not neutralized heterologous the virus is
not neutralized
 Forced to replicate inside the macrophages
Facilitate infection

The increased number of dengue virus infected monocyte result

in increase t-cell activation

Result of increase level of cytokines and chemical mediators

The rapid increase in the level and the synergistic effects of the mediators
and histamine results to:

Increase vascular permeability, increase Malfunction

of
plasma leakage coagulation
system

Leakage in plasma into Hematemesis,

extra vascular Petechiae
compartment

Decreased blood volume Hypotension Shock Death

Decreased decreased narrowed
HCT & HCG BP PP
a2. Schematic Diagram (Client-Centered)

Predisposing Factor: Precipitating Factor:

Dengue is a universal infection Poor environmental sanitation
(presence of stagnant and
uncovered water), poor
practices in protecting self
against mosquitoes, aedes
aegypti

Mosquito bite

Dengue virus enters the body, carried by circulation and multiplies

Immune response by the body

(activation of the defense mechanism Fever
of the body to foreign bodies)

Cytokine and
Immune adherence
Prostaglandin Pain to platelets
Release

Extravasation Nasal Bone Platelet

injury/
of fluid mucosa marrow damage

Decreased Epistaxis Maturational arrest Thrombocytopenia

tissue perfusion of megakaryocytes

Petichiae
Coagulation defect

Bleeding

Decreased Hct and Hbg Decreased blood volume

b. Synthesis of the Disease

b.1 Definition of the Disease

Dengue hemorrhagic fever (DHF) are
acute febrile diseases, found in the tropics
and Africa, with a geographical spread
similar to malaria. One major difference,
however, is that malaria is often eradicated
in major cities, whereas dengue is often
found in urban areas of developed tropical
nations, including Singapore, Taiwan or
Brazil. Caused by one of four closely related
virus serotypes of the genus Flavivirus, family Flaviviridae, 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 (rarely Aedes albopictus) mosquito, which
feeds during the day. It is a specific syndrome that tends to affect children
under 10. DHF is also called Philippine, Thai, or Southeast Asian hemorrhagic
fever and dengue shock syndrome. This disease is used to be called "break-
bone" fever because it sometimes causes severe joint and muscle pain that
feels like bones are breaking. Health experts have known about dengue fever
for more than 200 years. Dengue fever is found mostly during and shortly
after the rainy season in tropical and subtropical areas.

The early phase of illness is indistinguishable from dengue fever. After

2 - 5 days, however (defervescence period), a few cases in the first infection,
in contrast with a significant number of cases after reinfection by another
serotype may present with thrombocytopenia (< 100.000 /mm3) and
hemoconcetration, the first usually preceeding the second. Hemorrhagic
manifestations may or may not occur; the spleen is not palpable, but hepatic
enlargement and tenderness is a sign of bad prognosis. Other manifestations
include pleural effusion and hypoalbuminemia, encephalopathy with normal
cerebrospinal fluid.
 Diffuse cappilary leakage of plasma is responsible for the
hemoconcentration. In the presence of hemoconcentration and
thrombocytopenia, the pacient is considered to be seized by dengue
hemorrhagic fever and classified according to the following World Health
Organization classification:

Grade I - thrombocytopenia + hemoconcentration. Absence of spontaneous

bleeding.
Grade II - thrombocytopenia + hemoconcentration. Presence of spontaneous
bleeding.
Grade III - thrombocytopenia + hemoconcentration. Hemodynamic
instability: filiform pulse, narrowing of the pulse pressure (< 20 mmHg), cold
extremities, mental conffusion.
Grade IV - thrombocytopenia + hemoconcentration. Declared shock, patient
pulseless and with arterial blood pressure = 0 mmHg (dengue shock
syndrome - DSS).

Incubation period: 3 - 6 days; some cases may reach 15 days.

b.2 Predisposing or Precipitating Factors

• Water stored within household or stagnant water in premises.
• High human population density; the more crowded the human
population, the higher the infection rate.
• The infection may occur at any age but it is common among school
children with the peak between 4 and 6 years old.
• When it comes to sex, both are equally affected.
• More frequent during rainy season or months.
• More prevalent in urban communities or localities.

b.3 Signs and Symptoms with Rationale

• Fever- as a compensatory mechanism of the body in response to
infection.
-this was manifested by them patient upon admission to the hospital
(January 5, 2008).
• Vomiting- due to gastric irritation.
-this was manifested by the patient upon hospital admission until the
day of the admission (January 5, 2008).
• Decreased appetite- due to weakness being experienced and caused
by other signs and symptoms of the disease.
-this was manifested by the patient a day prior to hospital admission
(January 4, 2008).
• Body Malaise- due to decreased appetite which makes her lessens
her food intake that led to body malaise.
-this was manifested by the patient prior to hospital admission until
two days after the admission (January 4, 2008 - January 7, 2008).
• Petechiae- this is caused by capillary fragility and thrombocytopenia.
-this was manifested by the patient the day of hospital admission until
two days after the admission (January 5, 2008 – January 7, 2008).
• Epistaxis - inflammation of the nose or sinuses and clotting disorder.
-this was manifested by the patient two consecutive days prior to
hospital admission (January 3, 2008 – January 4, 2008).
 V. THE PATIENT AND HIS CARE

A. Medical Management

a.1 IVF’s, NGT Feeding.

Date Ordered
Medical
Date Performed Indications or Client Response to
Management and General Description
Date Changed or Purposes The Treatment
Treatment
Stopped
IVF D.O.: January 5, Plain normal saline It is used to treat No actual side effects
D5 0.3% NaCl 2008 solution contains 308 dehydration and were seen
D.P.: January 5, mosm/L (Na, 154 me Q/L, shifting of fluid
2008 CI, 154 mEq/L) has pH of from vascular
4.5 to 7.0 and is usually system to the
D.C.: not changed supplied in volumes of dehydration space.
9L, 500 cc, 250 cc and To administer
100 cc. medication and
nutrients to the
body.

Blood Transfusion Blood transfusions No negative reaction.

A blood transfusion is a are done to
safe, common procedure
D.O.: January 5, replace blood lost
2008 in which blood is given to during surgery or a
you through an
D.P.: January 5, serious injury. A
intravenous (IV) line in
2008 one of your blood transfusion also
vessels.
may be done if
D.C.: not changed your body can't
make blood
properly because
of an illness.
NURSING RESPONSIBILITIES:
INTRAVENOUS FLUID (IVF)

Prior:
 Verify doctor’s order.
 Explain the procedure to SO.
 Obtain the necessary materials.

During:
1. Check IVF level.
2. Check for patency of tubing.
3. Check if IVF is infusing well.
4. Select a suitable vein for venipuncture.
5. Practice aseptic technique.

After:
1. Adjust the rate of fluids appropriate to needs of pt. as ordered.
2. Monitor IV flow and pt.’s response.
3. Monitor pt. for evidence of IV infiltration’s r/t complication such as pain, swelling and tenderness.
4. Check for presence of air in the tubing if there is, remove immediately.
5. Record all procedure done
NURSING RESPONSIBILITIES:
BLOOD TRANSFUSION

Prior:
• Verify doctor’s order.
• Explain the procedure to SO.
• Obtain the necessary materials.
• Check the blood if it is compatible to the patient.

During:

• Check for patency of tubing.

• Check if the patient is compatible with her position.
• Monitor patients vital sign
• Observe for signs of a reaction to the transfusion
• Practice aseptic technique.

After:
• Adjust the rate of fluids appropriate to needs of pt. as ordered.
• Observe for signs of a reaction to the transfusion
• Record all procedure done
b. Drugs
Date Ordered Route of General Action Client
Name of the
Date Taken or Administration Functional Response to
Drug; Generic Indications or
Given Dosage and Classification the Medication
Name Purposes
Date Changed Frequency of Mechanism of with Actual
Brand Name
or Discontinue Administration Action Side Effects
Generic Name: Date Ordered: 7.5 mg 30 Antihistamine, temporarily Clients fever was
relieves these
Dyphenhydramin January 5, 2008 minutes prior to Anticholinergic healed AEB the
symptoms of the
e BT common cold: lowering down
Date Taken or block the effect the temperature
• sneezing
Brand Name: Given: of histamine at H1 • runny nose of the client from
banophen, January 5, 2008 receptor sites • headache normal level
• minor
benadryl aches and
Date Changed or Histamine is pains The client may
• cough
Discontinued: released by the • sore throat manifested the
January 6, 2008 body during • nasal following side
congestion
several types of effects:
allergic reactions temporarily -dizziness and
and––to a lesser reduces fever drowsiness
extent––during -constipation
some viral
infections, such
as the common
cold. When
histamine binds
to its receptors
on cells, it
stimulates
changes within
the cells that
lead to sneezing,
itching, and
increased mucus
production.
Antihistamines
compete with
histamine for cell
receptors;
however, when
they bind to the
receptors they do
not stimulate the
cells. In addition,
they prevent
histamine from
binding and
 stimulating the
cells.
Diphenhydramine
also blocks the
action of
acetylcholine
(anticholinergic
effect) and is
used as a
sedative because
it causes
drowsiness.

Nursing Responsibilities Prior to Drug Administration:

• Get the temperature of the client.
• Assess fever; note for presence of associated sign.
 • Make sure that the 10 rights are applied.
• Check the patency of the IV tube.
Nursing Responsibilities During Drug Administration:
• Check if your giving the right dosage.
Nursing Responsibilities After Drug Administration:
• Provide opportunities for rest.
• Maintain a quiet environment.
• Instruct client or significant others to increase fluid and fiber-rich foods intake.

Name of the Date Ordered Route of General Action Indications or Client

Drug; Generic Date Taken or Administration Functional Purposes Response to
Name Given Dosage and Classification the Medication
Brand Name Date Changed Frequency of Mechanism of with Actual
 or Discontinue Administration Action Side Effects
Generic Name: Date Ordered: 8 mg IV now Antifibrinolytic • treatment Clients nose
of excessive
Tranexamic acid January 5, 2008 Inhibitors bleeding was
bleeding
Brand Name: resulting from been cured.
systemic or
Cyklokapron, Date Taken or inhibits the
local
Transamin Given: activation of hyperfibrinolysi
s
January 5, 2008 plasminogen to
• prophylaxis in
plasmin, a patients with
coagulopathy
Date Changed or molecule
undergoing
Discontinued: responsible for surgical
procedures
January 6, 2008 the degradation
of fibrin. Fibrin is
the basic
framework for
the formation of
a blood clot in
hemostasis.

Nursing Responsibilities Prior to Drug Administration:

• Assess patients for renal insufficiency, cardiovascular or cerebrovascular disease
• Make sure that the 10 rights are applied.
• Check the patency of the IV tube.
Nursing Responsibilities During Drug Administration:
 • tranexamic acid should be avoided in patients with acquired disturbances in colour vision; ophthalmic exam is
recommended before and during therapy if patient is treated beyond several days
• Check if your giving the right dosage.
Nursing Responsibilities After Drug Administration:
• Provide opportunities for rest.
• Maintain a quiet environment.
• Instruct client or significant others to increase fluid intake.

Date Ordered Route of General Action Client

Name of the
Date Taken or Administration Functional Response to
Drug; Generic Indications or
Given Dosage and Classification the Medication
Name Purposes
Date Changed Frequency of Mechanism of with Actual
Brand Name
or Discontinue Administration Action Side Effects
Generic Name: Date Ordered: IV 150 mg every Antiinffectives Treat many Clients presence
different types of
Ampicillin January 5, 2008 6 gour (-) ANST of infection was
Brand Name: Belonging to the infections, such been lessen and
as tonsillitis,
Ampicin, Date Taken or penicillin group of had been
pneumonia,
Omnipen, Given: beta-lactam bronchitis, prevented the
urinary tract
Principen, January 5, 2008 antibiotics, other
infections,
Totacillin ampicillin is able gonorrhea, and complication that
infections of the
Not Changed or to penetrate may occur
intestines such
Discontinued Gram-positive as salmonella because of
and some Gram- infection
negative
bacteria. It differs
from penicillin
only by the
presence of an
amino group. The
amino group
helps the drug
penetrate the
outer membrane
of gram-negative
bacteria.
Ampicillin acts as
a competitive
 inhibitor of the
enzyme
transpeptidase.
Transpeptidase is
needed by
bacteria to make
their cell walls. It
inhibits the third
and final stage of
bacterial cell wall
synthesis, which
ultimately leads
to cell lysis.
Nursing Responsibilities Prior to Drug Administration:
• Provide patients after negative skin test
• Make sure that the 10 rights are applied.
• Check the patency of the IV tube.
Nursing Responsibilities During Drug Administration:
• Ampicillin and gentamicin should not be mixed in the same I.V. tubing or administered concurrently
• Check if your giving the right dosage.
Nursing Responsibilities After Drug Administration:
• Provide opportunities for rest.
 • Maintain a quiet environment.
• Instruct client or significant others to increase fluid intake.

Date Ordered Route of General Action Client

Name of the
Date Taken or Administration Functional Response to
Drug; Generic Indications or
Given Dosage and Classification the Medication
Name Purposes
Date Changed Frequency of Mechanism of with Actual
Brand Name
or Discontinue Administration Action Side Effects
Generic Name: Date Ordered: PO 1 ml once a Vitamin Vitamin C is Clients get well
required for the
Vitamin C January 5, 2008 day Suplements faster because
growth and repair
Brand Name: of tissues in all one action of
parts of your
Date Taken or Ascorbate is an vitamin c is to
body. It is
• Ascorbicap Given: antioxidant, as it necessary to promote stronger
form collagen, an
• Cebid January 5, 2008 protects the body immune system
important protein
 against oxidative used to make to fight for the
Timecelles skin, scar tissue,
Date Changed or stress, and is a other diseases
tendons,
• Cecon Discontinued: cofactor in ligaments, and may occur
blood vessels.
January 6, 2008 several vital
• Cecore 500 Vitamin C is
enzymatic essential for the
• Cee-500 healing of
reactions.
wounds, and for
the repair and
• Cemill
maintenance of
cartilage, bones,
• Cenolate
and teeth.
• Cetane

• Cevi-Bid

• Flavorcee

• Mega-C/A Plus

• Ortho/CS

• Sunkist

Nursing Responsibilities Prior to Drug Administration:

• Make sure that the 10 rights are applied.
Nursing Responsibilities During Drug Administration
• Check if your giving the right dosage.
Nursing Responsibilities After Drug Administration:
• Provide opportunities for rest.
• Maintain a quiet environment.
• Instruct client or significant others to increase fluid intake.

c. Diet
Date
Client’s
ordered
Type of response
Date General Indication (s) Specific food
diet and/ or
started description Or Purpose (s) taken
reaction to
Date
diet
change

DAT (Diet DO: The pt can eat Since the pt. taken NPO and soft Foods rich in The patient
CHON, CHO,
as January 5, foods rich in CHO, diet, she needs to eat food rich in S.O complied
Vit.C, and
tolerated) 2008 CHON Vit C, Fe, CHO, CHON, VIt.C, and adequate adequate with the diet
intake of fluids.
Not and drink fluids as intake of fluids to increase energy regimen
discotinue tolerated and to prevent infection and for
 tissue repair for immediate healing
and damaged cells.

Nursing Responsibilities (Diet)

Prior to/ in giving the diet:

 Monitor the client and assess for signs of weakness.
 Explain to the pt. S.O. the purpose of the dietary recommendation to her current condition.

During to/ in giving the diet:

 Be sure that the patient is taking or eating foods she can tolerate.
 Assess patient’s condition and how she responded on the foods she is taking.
 Try to give fruits and vegetables.

After to/ in giving the diet:

  Encourage the patient to have a regular eating habit.
 Assess patient for signs of allergy, contentment and other factors after eating.
 Observe patient’s satisfaction on the food she ate.

C. NURSING MANAGEMENT

1. Nursing Care Plan

PROBLEM NO. 1
ASSESSMEN NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EXPECTED
T DIAGNOSIS EXPLANATION S INTERVENTION OUTCOME
S
S: ø Hyperthermi The condition of Short Term: > establish > to gain the Short Term:
a dengue rapport trust and
O: hemorrhagic After 3 hours coo-peration After 3
fever indicates of nursing of the SO hours of
The patient the presence of intervention nursing
manifests: infection into an s, pt’s. > assess V/S > to gain intervention
individuals temperature base-line s, Pt’s. temp
> skin warm body. The will be data for the shall
to touch infection decreased care and decreased
> body temp. triggers an from 37.7oC management from 37.6oC
of 37.7oC inflammatory to 37oC. to the to 37oC.
> increased response of an patient.
HR of 135 increase in WBC Long Term: > determine
bpm and plasma precipitating fx >identificatio
> increased proteins in the After 5 days and underlying n and Long Term:
RR of 40 bpm blood. These of nursing cause management
WBCs, intervention of the After 5 days
specifically the s, pt. will be underlying of nursing
The pt. may leukocytes and free from cause are intervention
manifest: macrophages infection essential to s, Pt. shall
releases a fever AEB V/S recovery be free from
> diaphoresis causing within > monitor Lab infection
> irritability chemical known normal limits results (WBC > WBC and AEB V/S
> as pyrogens. and WBC count, serum other lab within
dehydration Once count within electrolyte, results show normal
> fluid or recognized by normal serum sodium) the body’s limits and
electrolyte the thermore- range. coping WBC count
imbalance gulatory center mechanisms within
> convulsions of the brain > control normal
triggers an environmental > controlling range.
increase in the temperature the
body’s core environment
temperature, al temp. will
which could prevent the
then lead to the client from
killing of the experiencing
infection chills
(microorganism > remove or
). loosen excess > these
clothing and decreases
cover warmth and
increases
evaporation
cooling

> provide ample

fluids by mouth >to maintain
or intravenously fluid balance
> provide TSB
(do not use > alcohol
alcohol) cools the skin
too rapidly,
causing
shivering

> provide > this is

information specifically
regarding necessary for
normal V/S and pt. or in
control if there situations
is deviations. with
infections

> discuss
precipitating fx > for faster
and preventive healing and
measures recovery
including
maintenance of
adequate fluid
intake,
protective skin
products,
change in env’t,
and taking meds
as prescribed.

>administer
medications per > for faster
doctor’s order recovery. It is
used to treat
the client’s
disease
condition.
PROBLEM NO. 2
NURSING
ASSESSMEN NURSING SCIENTIFIC EXPECTED
OBJECTIVES INTERVENTION RATIONALE
T DIAGNOSIS EXPLANATION OUTCOME
S
S: ø Risk for fluid Our body Short Term: > establish > to gain the Short Term:
volume maintains fluid rapport trust and
O: deficit balance After 3 hours cooperation of After 3 hours of
related to through of nursing the SO nursing
The patient restriction of maintaining the interventions, interventions,
manifests: diet balance The pt and > assess V/S > to gain The pt and SO
>appears secondary to between I and SO will be base-line data shall demonstrate
weak disease O. However, the able to for the care behaviors to
>dry skin condition pt manifests demonstrate and monitor deficit as
vomiting but behaviors to management indicated
the patient was kept on monitor of the patient.
may manifest: NPO. So, the deficit as >assess pt’s Long Term:
> oliguria tendency is indicated general condition >to indicate
>decrease that, there is an presence of After 5 days of
>venous filling increase in Long Term: complications nursing
>hypotension output while and determine interventions, pt.
>increased there is a After 5 days appropriate shall maintain
>pulse rate decreased in of nursing management fluid volume at a
>change in pt’s input interventions, to the pt. functional level
skin turgor resulting to the pt. will > determine AEB individually
>change in patient’s being maintain fluid precipitating fx >identification adequate urinary
mental status at risk in fluid volume at a and underlying and output and stable
>increased in deficit. functional cause management V/S, moist mucus
body level AEB of the membranes and
temperature individually underlying good skin turgor.
adequate cause are
urinary essential to
output and recovery
stable V/S, >administer
moist mucus medications per > for faster
membranes doctor’s order recovery. It is
and good used to treat
skin turgor. the client’s
disease
 condition.
>monitor bp and
note presence of >to monitor
physical signs hydration
status.
PROBLEM NO. 3
NURSING
ASSESSMEN NURSING SCIENTIFIC EXPECTED
OBJECTIVES INTERVENTION RATIONALE
T DIAGNOSIS EXPLANATION OUTCOME
S
S: ø risk for Platelets are Short Term: > establish > to gain the Short Term:
injury the clotting rapport trust and
o
O: (bleeding) factors of the after 4 of NI cooperation after 4o of NI
r/t altered blood. They the pt’s SO of the SO the pt’s SO
The patient clotting should be will verbalize shall
manifests: factor maintained understandin > assess V/S > to gain verbalize
>petichiae secondary to within normal g of base-line understandin
>decreased disease ranges in order individual data for the g of individual
platelet count condition to prevent factors that care and factors that
of 140x109 bleeding. In the contribute to management contribute to
pt’s case, she is possibility of of the possibility of
experiencing injury and patient. injury and
the patient Dengue take steps to take steps to
may manifest: hemorrhagic correct >assess pt’s >to indicate correct
>(+) fever, wherein situations general condition presence of situations
tourniquet test there is faulty complication
>fever maturation of Long Term: s and Long Term:
>hematemesi the determine
s megakaryocyte After 5 days appropriate After 5 days
>melena s which results of nursing management of nursing
>ecchymoses in the interventions, of the pt. interventions,
diminished pt. will be pt. shall be
production of free from > provide >to assist free from
platelets even injury information the SO to injury
though there is regarding reduce or
excessive disease condition correct
consumption of individual
platelets due to risk factors
generalized >identify safety
intravascular devices >to promote
clotting, putting safe physical
her at risk of environment
bleeding. and
individual
safety
PROBLEM NO. 4
NURSING
NURSING SCIENTIFIC EXPECTED
ASSESSMENT OBJECTIVES INTERVENTION RATIONALE
DIAGNOSIS EXPLANATION OUTCOME
S
S: ø risk for The three major Short Term: > establish > to gain the Short Term:
injury functions of the rapport trust and
O: (bleeding) colon: mucosal after 4o of NI cooperation of after 4o of NI
r/t altered transport, the pt and SO the SO the pt and SO
The patient clotting myoelectrical will will
manifests: factor 2 activity and the demonstrate > assess V/S > to gain demonstrate
>no bowel disease processes of behaviors to base-line data behaviors to
movement for condition defecation. Any prevent for the care prevent
3 days interference constipation and constipation
>Irregular with the management
defacation previously Long Term: of the patient. Long Term:
habits identified >assess pt’s
>Insufficient functions of the After 3 days general condition >to indicate After 3 days of
physical colon could lead of nursing presence of nursing
activity to constipation. interventions, complications interventions,
>Recent The urge to pt. and SO and determine pt. and SO
environmental defecate will be able appropriate shall maintain
changes stimulated to maintain management usual pattern of
normally by usual pattern of the pt. bowel
 rectal of bowel >palpate functioning
the patient distention, functioning abdomen > to assess
may manifest: which initiates a presence of
>dry, hard, series of four abdominal
formed stool actions: distension
>straining stimulation of >promote
with the internal adequate fluid >to promote
defacation sphincter intake moist/ soft
>distended muscles, stool
abdomen relaxation of
>hypoactive the external
bowel sounds sphincter
>anorexia muscle and
muscles in the
pelvic region,
and increased
intraabdominal
pressure.
Interference
with any of
these processes
can lead to
 constipation,
Physical activity
could lead to
stimulation of
contractions of
the intestines,
but if physical
activity is
insufficient, it
could lead to
constipation

PROBLEM NO. 5
ASSESSMEN NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED
T DIAGNOSIS EXPLANATION INTERVENTION OUTCOME
 S
S: ø Ineffective Due to the Short Term: > establish > to gain the Short Term:
airway presence of rapport trust and
O: clearance r/t allergens, the after 5 hours cooperation of after 5 hours of
retained bronchial wall of nursing the pt. and the nursing
The patient secretions tries to wash interventions SO interventions
manifests: them of by the pt will be the pt shall
>non increasing able to > assess V/S > to gain demonstrate
productive mucus demonstrate base-line data behaviors to
cough production. The behaviors to for the care maintain airway
slight colds mucus when maintain and patency
not airway management
expectorated patency. of the patient. Long Term:
the patient will be retained >assess pt’s
may manifest: blocks the air Long Term: general condition >to indicate After 3 days of
>dyspnea passage presence of nursing
>abnormal causing an After 3 days complications interventions,
breath sounds ineffective of nursing and determine pt. and SO shall
>changes in airway interventions, appropriate maintain airway
respiratory clearance pt. and SO management patency
rate and will be able of the pt.
rhythm to maintain >promote
>difficulty airway adequate fluid >to liquefy
vocalizing patency intake, and secretions
>restlessness encourage warm
>orthopnea versus cold
>vocalizing liquids

>position heads > to open or

maintain
midline with
airway in at
flexion
rest or
compromised
individual

>to assess
>auscultate
condition of
breath sounds
the respiratory
tract

VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL

1. Clients Daily Progress Chart

 Admission Discharge
DAYS 06 07 08
01-05-08 01-09-08

Nursing Problems:
X X
1. Hyperthermia

2. Risk for fluid

volume deficit
related to
X
restriction of diet
secondary to
disease condition

3. Risk for injury

(bleeding) r/t
altered clotting X
factor secondary to
disease condition

4. Risk for injury

(bleeding) r/t
altered clotting X
factor secondary to
disease condition

5. Ineffective airway
X X X X
clearance r/t
retained secretions

Temp 37.9°C 37.8°C 36.2°C 36°C

PR 120bpm 110bpm 100bpm 118bpm

VS
RR 30cpm 62cpm 32cpm 48cpm
2. DISCHARGE PLANNING

a. General Condition of Client upon Discharge

Last January 9, 2008, baby Deng was discharge after being

admitted in the hospital for almost four consecutive days. Before
leaving the hospital, the student-nurses assessed her general condition
for the last time. Baby Deng appears to be in a much better condition
as she was before. She was also actively interacting with the student-
nurses as they assess her. The petechiae she manifested in her
extremity were all gone. She is more responsive than before and does
not appear lethargic.

Before leaving the ward, her aunt asked the student-nurses to

touch baby Deng’s back or as they call in Kapampangan, “apisan”. This
act serves as a precautionary measure or a counter against their belief
of “asug”.

b. METHOD

M: The take-home medicines of the patient includes

• Cefalexin (antibiotic, antibacterial)
• Pedialyte (oral electrolyte solution)

E: ø

T: Emphasized to SO the importance of compliance to medical regimen

especially to medication intake

H: Health teachings given to the patient includes

• Instructed SO to provide patient with adequate rest periods
 • Instructed So to observe for any signs of bleeding and refer
immediately to a health care provider
• Instruct SO to increase patient’s fluid intake or as tolerated to
prevent dehydration, replace fluid loss and maintain fluid balance

O: To be back after one week (January 16, 2008)

D: Instructed mother to continue breast feeding

VII. CONCLUSION AND RECOMMENDATION

Conclusion
Dengue hemorrhagic fever (DHF) is a severe, potentially deadly
infection spread by certain mosquitoes world wide. More than 100 million
cases of dengue fever occur every year. A number of these develop into
dengue hemorrhagic fever. (http://adam.about.com)

Although potentially deadly, DHF is something that could be prevented

and controlled; through the use of appropriate information and techniques
in eradicating the spread of the disease.

Moreover it is up to our own initiative to become aware and do

something about this. We should always keep ourselves protected and keep
our surroundings clean. Our role as future nurses as health teachers we
should make sure we provide the public with information that is applicable for
them and encourage them to apply it in their day to day activities. To be able
raise the awareness of the public regarding this disease in order to lessen the
possible occurrence of this condition

Recommendation
 The mortality or death rate with dengue hemorrhagic fever is
significant. It ranges from 6% - 30%. Most death occurs in children. Infants
under a year of age are especially at risk of dying from DHF. Health care
providers are to give appropriate information, care and treatment to a person
who is sick.

Primary prevention of namely resides in mosquito control; eliminating

and reducing the vectors. Vector control is implemented using environmental
management and chemical method. Proper solid waste disposal and
improved water storage practices, including covering containers to prevent
access of mosquitoes are among the methods that are being encouraged.
Through the use of these technique and intervention, we are surely capable
of decreasing the occurrence of dengue in our communities.

As for all nurses, they should give the patient information about her/his
disease so he/she will know her condition. At the same time giving out health
teachings is very essential so that he/she will be cautious the next time and
minimize the risk of him/her acquiring the disease again.

VII. BIBLIOGRAPHY
 a. Book Source:
• Seeley, et al.; Essentials of Anatomy and Physiology

b. Internet source:

• http://www.searo.who.int/en/Section10/Section332/Section522_2
515.htm

• http://www.who.int/mediacentre/factsheets/fs117/

• http://en.wikipedia.org/wiki/Dengue_fever

• http://en.wikipedia.org/wiki/Blood

Learning Derived

As future health care providers, we are expected to care for the sick
and in addition to that, we should be equipped with the appropriate
knowledge and skills to be able to handle any unexpected situation that could
arise in any setting. We should be able to utilize these knowledge and skills
to provide others with health teachings, to make prevention and cure as
possible.

Through the course of our case study, I was able to gain new
knowledge and insights which I could apply the next time I encounter a
patient diagnosed with DHF. While learning, I was also able to enhance my
ability to interact and communicate with our client; establishing rapport more
efficiently.

At the end of our duty in ONA,