Case study:

Dengue
 TABLE OF CONTENTS
1. Introduction
2. Objectives of the study

-general objectives

-specific objectives

3. Theoretical framework

4. Nursing health history

-demographic data

-history of present illness

-past medical history

-family history

-social history

-environmental history

-genogram

5. Gordon’s level of functioning

6. Physical assessment

7. Laboratory exams

8. Anatomy and physiology

9. Pathophysiology

10. medical/surgical intervention

11. Drug study

12.nursing care plan

12. Discharge plan

12. Bibliography
 INTRODUCTION

This case is a about a 13 years old boy who was admitted at Capitol medical center on
September 21, 2012 with a chief complaint of fever and was diagnosed with dengue.

Dengue fever is a disease cause by a family of viruses that are transmitted by ‘’Aedes’’
mosquitoes. This mosquito transmits the disease by biting an infected person and then biting
someone else. The mosquitoes that transmit dengue live among human and breeds in
discarded tires, flower pots, old drums and water storage containers close to human dwellings.

Unlike the mosquitoes that cause malaria, dengue mosquitoes bit during the day.
Symptoms such as headache, fever, exhaustion, severe joint and muscle pain, swollen glands
(lymphadenopathy), and rash. The presence (the "dengue triad") of fever, rash, and headache
(and other pains) is particularly characteristic of dengue fever

MANILA, Philippines -- Global warming may have contributed to a 43 percent rise in the
number of dengue cases in the Philippines for the first half of the year. The biggest increase in
the country was seen in Metro Manila, where there was an almost 200 percent increase. "The
increase in the number of dengue cases may be attributed to the constantly changing climate
brought by global warming as well as congestion in urban areas,"
World Health Organization officials earlier this year warned climate change was increasing the
incidence of dengue fever and other infectious diseases in the country. There is no known cure
or vaccine for dengue fever, which is transmitted by the white-spotted mosquito.
 OBJECTIVES OF THE STUDY

General objectives

 the main goal of the study is for me to have an additional knowledge related to

pneumonia and to develop my skills in assessing a patient with pneumonia

Specific objectives

 interpret data gathered from the patient identify and explain etiology of the underlying

condition

 discuss the anatomy and physiology of the related disease

 trace the pathopysiology of the disease

 explain how the theoretical framework relates to the patients present condition

 discuss the Gordon’s pattern of functioning and physical assessment obtained

 classify the drugs being taken by the patient

 carry out interventions that were discussed in the nursing care plan
 THEORETICAL FRAMEWORKS

Environmental theory

Florence nightingale was born on May 12 1820. She was the founder of modern nursing and the first
nursing theorist. Also known as "The Lady with the Lamp She was the first to propose nursing required
specific education and training. Her contribution during Crimean war is well-known.

Assumptions of nightingale’s theory

 Natural laws
 Mankind can achieve perfection
 Nursing is a calling
 Nursing is an art and a science
 Nursing is achieved through environmental alteration
 Nursing requires a specific educational base
 Nursing is distinct and separate from medicine

Nightingale’s canons: major concepts

 Ventilation and warming

 Light, Noise
 Cleanliness of rooms/walls
 Health of houses
 Bed and bedding
 Personal cleanliness
 Variety
 Chattering hopes and advices
 Taking food. What food?

Nightingale's documents contain her philosophical assumptions and beliefs regarding all elements found
in the metaparadigm of nursing. These can be formed into a conceptual model that has great utility in
the practice setting and offers a framework for research conceptualization
 4-digm

Nursing

Nursing is different from medicine and the goal of nursing is to place the patient in the best possible
condition for nature to act.
Nursing is the "activities that promote health (as outlined in canons) which occur in any caregiving
situation. They can be done by anyone."

Person
People are multidimensional, composed of biological, psychological, social and spiritual components.

Health

Health is “not only to be well, but to be able to use well every power we have”.
Disease is considered as dys-ease or the absence of comfort.

Environment
"Poor or difficult environments led to poor health and disease".
"Environment could be altered to improve conditions so that the natural laws would allow healing to
occur."

In a relation to the patient,

In the case of the patient wherein she manifested dengue, it can be correlated with the theory of
nightingale where in the environment of the patient is a factor leading to recovery, having a clean
environment, well organized house, nurturing environment and taking fruits and vegetables, the body
could repair itself.
 NURSING HEALTH HISTORY
A. personal history
Name: MT
Age: 13
Address: cordero 8th avenue grace park Caloocan city
Birth day: July 25, 1999
Sex: male
Civil status: single
Religion: roman Catholic
Attending physician: Dr. Naidas
Admission diagnosis: systemic viral illness ruled out dengue fever
Admission date: September 21, 2012
Chief complaint: Fever

B. history of present illness

4 days prior to admission patient had colds. 1 day prior to admission patient was noted to be
febrile at (40. O C) paracetamol was given and the patient consulted a local clinic and was
diagnosed with acute tonsillopharyngitis. Co-amoxiclav was prescribe patient was able to take
medication for 3 days

C. past medical history

Patient was healthy but he had been admitted to the hospital several times before. His last
admission was on February 2012 due to scarlet fever. And he also has bronchial asthma. And his
vaccination was unrecalled

D. personal/social history
Patient is now in grade 7. He lives with his mother, father and his siblings. The patient is a Non-
smoker and Non-alcoholic drinker. He was also inclined to sports like basketball, and sometimes
he plays badminton for past time. He loves to eat chicken and pork but he hates vegetables.

E. Environmental history
Patient lives in an urban area which is not crowded but somehow semi-polluted

F. Family health history

Patient‘s father who resides in Caloocan together with his Family doesn’t have any history of
other diseases aside from hypertension which were treated by medications prescribed by their
physician. Similarly, they have also stated that the family is not sports-inclined and has not
practiced much of their active lifestyle. Usually they spend their time at work and at home
watching television and movies and enjoy occasional drinking. On the other hand, her mother
who grew up in Caloocan had a history of diabetes and asthma.
 GORDON’S PATTERN OF FUNCTIONING

Pattern Before hospitalization During hospitalization Analysis

1. Health The patient takes The client health is The patient can manage
perception vitamins and but good the fever resided, his health, he informed the
maintenance doesn’t eat vegetable. but the rashes on his nurse whenever he feels
The patient have skin were still there. something wrong, and it
regular checkups yearly And his family really helps the medical
with his physician informed the nurse on staffs to treat him.
duty when the client’s
temp. Increased.
2. Nutritional Eat 3 meals per day He’s on DFA and NDCF, still There are no many
metabolic and sometimes take eats 3 times a day. And he changes in patient’s
pattern midnight snacks. And had an on-going IV fluid. nutritional and
consume 5-6 glasses of And takes 600 cc of water metabolic pattern. And
water per day per day the client has proper
diet and fluid intake
3. Elimination The patient defecates The client still urinates There are no many
pattern once a day without any 4 to 5 times a day and changes in patient’s
discomfort and it is defecated once a day elimination pattern
well formed. he usually
urinates 4 or 5 times a
day without any pain or
discomfort
4. Activity and Have no regular The patient lies on bed There is minimal
exercise pattern exercise but he plays most of the time, and activities due to his
basketball and not allowed to mobilize hospitalization
badminton. as much due his IV.
5. Sleep and rest The client sleep’s 6 to 7 The client has no The clients sleeping
pattern hrs without difficulties. choice but to sleep and routine has been
Usually sleeps 11pm to rest, but he has changed. Patients sleep
5 am. difficulty of sleeping was disturbed because
because of the nurses of the nurses and
and doctors rounds doctors rounds
6. Cognitive and Patient is alert and well Patients easily There are no changes
perceptual oriented understands and in client’s cognitive and
pattern cooperates well perceptual pattern. The
client can express
himself but doesn’t
communicates well
7. Self-perception The patient is serious The patient is not that The patients is irritable
and self- and family centered approachable but very because of her
maintenance cooperative, he is condition, but can
always surrounded by cooperate with the
his family others
8. Role relationship The patient is the The patient is always The patient is
pattern youngest son. And he accompanied by his independent but
 lives with his mother, oldest brother, and his somehow depends on
father and brothers relatives visits once in his brother due to his
awhile condition
9. Sexuality the patient is not The patient doesn’t There is still no changes
reproductive sexually active perform any sexual in the patient’s
activities sexuality reproduction
10. Coping/stress The patient doesn’t the patient seems The client is not
tolerance encounter much bored and somehow comfortable because
problem, and his unhappy, and he plays he is hospitalized and
always happy laptop to entertain wanted to go home
himself soon
11. Values and The client is a roman The clients still have The client is religious
beliefs catholic. he goes to time to pray every and even though he is
mass every Sunday night together with his hospitalized he had
with his family, and brother time pray
pray every night before
going to sleep

PHYSICAL ASSESSMENT

General findings Normal Findings Analysis

height 4’5-5’3 5’2 Height is in the normal
range
weight 45.3-49.8 54 Weight is not in the
normal range
temperature 36.5-37.5 36.6 Temperature is in the
normal range
Pulse rate 60-100 80 Pulse rate is in the
normal range
Respiratory rate 12-20 20 Respiratory rate is in
the normal range
Blood pressure 90/60 to 130/90 100/70 Blood pressure is in the
normal range

Area assessed Technique Normal Findings Analysis

findings
A. Skin
Color Inspection Light brown, Light brown in Due to dengue
tanned skin color, has pink
(may vary rashes
according to race)
Moisture Inspection/palpation Skin normally dry Normally dry Normal
Temperature Palpation Normally warm Warm to touch Normal
Texture Palpation Smooth and soft smooth and soft Normal
Turgor Palpation Skin snaps back Skin snaps back Normal
immediately immediately
Skin appendages
Nails Inspection Transparent, Transparent, Normal
smooth and smooth and
convex convex
Nails bed inspection Pinkish Pinkish Normal
Nails base Inspection Firm Firm Normal
Hair distribution Inspection Evenly distributed Evenly distributed Normal
Color Inspection Black to light black Normal
brown
Upper extremities Normal
Arms Palpation/inspection Warm to touch Warm to touch Normal
and tenderness and tenderness
Palms and dorsal Palpation/inspection Pinkish and Pinkish and Normal
surface slightly rough slightly rough

Shoulders Inspection Perform w/o any Perform w/o any Normal

difficulty difficulty
Elbows Inspection Perform without Perform without Normal
any difficulty any difficulty
Skull Inspection Normal
Generally round Generally round
Eyes
Eyes Inspection Normal
Non protruding Non protruding
Eyebrows Inspection Symmetrical in Symmetrical in Normal
size, extension, size, extension,
hair texture and hair texture and
movement movement
Eyelashes Inspection Normal
Evenly distributed Evenly distributed
Eyelids Inspection Normal
Same color as skin Same color as skin
Conjunctiva Inspection Normal
Transparent with Transparent with
light pink color light pink color
Sclera Inspection Color white Color white Normal
Ears Normal
Inspection Free of Lesions, Free of Lesions,
discharge or discharge or
inflammation inflammation
Hearing acuity Inspection Client normally Client normally Normal
hears words when hears words when
whispered. whispered.
Nose Inspection Nose in the Nose in the Normal
 midline; no midline; no
discharges; no discharges; no
bone or cartilage bone or cartilage
deviation noted. deviation noted.
neck Inspection/palpation Normal
No visible mass or No visible mass or
lumps; lumps;
symmetrical; no symmetrical; no
jugular venous jugular venous
distension. distension.

Lymph nodes inspection Normal

May not be May not be
palpable; non- palpable; non-
tender IF tender IF
PALPABLE; less PALPABLE; less
than 1cm in size. than 1cm in size.
Thyroid Inspection Normal
Normally non- Normally non-
palpable; no palpable; no
nodules palpable nodules palpable

Thorax

Lungs Auscultation Normal

Illustrate Illustrate
voluntary sound voluntary sound

Cardiovascular Inspection Normal

Pulse visible; no Pulse visible; no
lift or heaves. lift or heaves.
Abdomen inspection Normal
Skin color is Uniform color to
uniform, no the rest of the
lesions; some may skin
have presence of
striae or scars
lower extremities Inspection Equal in size; no Normal
Equal in size; no edema; no
edema; no crepitus
crepitus
 LABORATORY EXAM
HEMATOLOGY
Latest report
September 23, 2012

Test Actual findings Normal findings Analysis/interpretation

Hemoglobin 163 g/l 135-160 The no. of hemoglobin
increased indication of
poor oxygen supply
Hematocrit 0.48 0.40-0.48 normal
Erythrocytes 5.59 10’12/l 4.5-5.0 The no. of erythrocytes
increased indicates that
the red blood cells are
carrying less oxygen
than normal
MCV 87.70 fl 80-96 Normal
MCH 29.20 pg 27-33 Normal
MCHC 33.30 g/dl 33-36 Normal
Total WBC 3.4 10’g/l 5.0-10.0 The no. of WBC count
decreased indication of
vulnerable to potential
serious infection which
is dengue
Nuetrophils 0.37 0.55-0.65 The no. of neutrophils
decreased resulted to
underlying condition
which is dengue that
affects the cell
production
Lymphocytes 0.53 0.25-0.40 The no. of lymphocytes
increased because of
the infection
Monocytes 0.06 0.02-0.06 Normal
Stabs 0.04 0.01-0.05 Normal
Platelet count 230 150-440 Normal

Previous
September 22, 2012
 Test Actual findings Normal findings Analysis/interpretation
Hemoglobin 146 135-160 Normal
Hematocrit 0.44 0.40-0.48 Normal
Erythrocytes 4.98 4.5-5.0 Normal
MCV 87.30 80-96 Normal
MCH 29.30 27-33 Normal
MCHC 33.60 33-36 Normal
Total WBC 4.1 5.0-10.0 The no. of WBC count
decreased indication of
vulnerable to potential
serious infection which
is dengue
Nuetrophils 0.65 0.55-0.65 Normal
lymphocytes 0.25 0.25-0.40 Normal
Monocytes 0.06 0.02-0.06 Normal
Stabs 0.03 0.01-0.05 Normal
Platelet count 213 150-440 Normal

ANATOMY AND PHYSIOLOGY

BLOOD
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients
and oxygen to the cells and transports metabolic waste products away from those same cells.

PHYSICAL CHARACTERISTIC

Bright red (oxygenated) dark red/purplish (unoxygenated). Much more dense than pure water. pH
range from 7.35 to 7.45 (slightly alkaline). Slightly warmer than body temperature 38.Celsius. Typical
volume in adult male 5-6 liters typical volume in adult female 4-5 liters typically 8% of body weight

COMPONENTS OF BLOOD

The blood is considered to be the only fluid tissue in the body. It is complex connective tissue in which
formed elements are suspended in a nonliving fluid matrix called plasma. The plasma is the liquid part of
the blood and is approximately 90% water.

3 formed elements in the blood

1. Erythrocytes- responsible for blood gas transport

2. Leukocytes – defends body from infection or disease
3. Platelets- needed for normal blood clotting
(in this case, platelets are the ones mostly affected by the dengue virus so this will be our focus)
Blood cell formation/hematopoieses (platelets)

Hematopoieses occurs in the red bone marrow or the myeloid tissue. Red bone marrow is found
chiefly in flat bones like the skull, pelvis, the ribs, sternum, humerus and femur. All of the formed
elements arise from a common type of stem cell called hemocytoblast which resides in the red bone
marrow

The hemocytoblast stem cells develop into lymphoid or myeloid stem cells. Myeloid stem cells
by then will developed as platelets or other formed elements depending on the response of the
changing body needs and different stimuli. Like any other formed elements in the blood, platelet
production is stimulated by the hormones. The hormone thrombopoietin accelerates the
production of platelets but only little is known about how this process is regulated

PLATELETS

Platelets are not cells in a strict sense. They are fragments of bizarre multinucleated cells of
megakaryocytes. They appear as darkly stained and irregularly shaped. The nominal platelet count is
150,000 – 500,000 per cubic millimeter.

PHYSIOLOGY OF PLATELETS

Platelets are responsible for normal blood clotting. If we are going to live without it, a single cut
would lead us out to death. There is a process called hemostasis wherein platelets have a major role.
Hemostasis means stooping of bleeding. It happens when a blood vessel breaks or injured. Hemostasis
occurs in three major phases which occur in rapid sequence.
1. Vascular spasms occur – the immediate response of the body to blood vessel injury
 2. Platelet plug forms – when the endothelium is broken, the collagen fibers are exposed that
leads to clinging of the platelets to the damage site and making them sticky. Platelets
released more chemicals that attract more platelets to the site of damage.
3. Coagulation event occurs
A. Injured tissues released tissue factors (TF), substances that plays an important role
in clotting.
B. PF3 which is a phospholipid, coats the surfaces of the platelets, interacts with the TF,
Vit K, calcium ions and other protein clotting factor
C. Prothrombin activator for conversion of prothrombin to thrombin which is an
enzyme.
D. Thrombin joins fibrinogen proteins to form long hair like molecules of insoluble
fibrin which forma netlike meshwork’s that traps RBCs and forms the basis of the
clot.

PATHOPHYSIOLOGY (BOOK-BASED)

Predisposing factors Precipitating factors

 Geographical area:  Environmental conditions
Caloocan city (stagnant water as breeding sites)
 Dengue carrier mosquitoes
 Activity (student)

Replication of virus in mosquitoes’ salivary

glands

Bite to skin from dengue carrier mosquito (itchiness and redness

at the bite area)

Dengue virus is inoculated in the blood with 8 -14 days incubation period

Virus disseminates rapidly in the blood stimulating WBCs and B

lymphocytes and produces antibodies and macrophages
 Macrophages performs phagocytosis; dengue virus
replicates within the cells, antibodies attach to viral
antigents

Entry to the spleen Release of cytokines and other Entry to the bone
platelet activating factors that marrow
stimulates WBCs and pyrogen
release

DENGUE
s/s:
 High grade fever
 Flushed skin
 Headache
 Pink rashes on the skin

If Treated:

 HYDRATION: IV
infusion; increased
If not treated:
fluid intake
Complications such:
 Drug therapy:  Intense bleeding
antipyretic  Severe hypertension
(Paracetamol)  Pulmonary edema
 Careful monitoring  Shock
condition  Liver cirrhosis

RECOVERY DEATH
 DRUG STUDY

DRUG MECHANISM INDICATION CONTRAINDICATION SIDE NURSING

OF ACTION EFFECTS RESPONSIBILITIES
Paracetamol Produce Relief of Anemia, cardiac and Allergic skin Assess for allergy
(biogesic) analgesia by fever, minor pulmonary disease. reactions and Reassess the Pt’s
500mg/tab 1 blocking pain aches and Hepatic or severe renal GI vital signs
tab PRN impulses by pains disease disturbances
inhibiting
prostaglandin
synthesis in
the CNS or of
other
substances
that sensitize
pain receptors
to stimulation.
The drug may
relief fever
through
central action
in the
hypothalamic
heat regulating
center.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Hyperthermia Short term Independent: Short term
related to goal: goal:
‘’ Ang init ko dengue After 30 mins -Establish -to gain pt’s After 30 mins
po’’ as of nursing rapport trust of nursing
verbalized by intervention intervention
the patient the patient will the patient
maintain core was
Objective: temperature -encourage -to prevent maintained
-flush skin within the pt’s to increase dehydration core
-skin is warm normal range fluid intake because temperature
to touch with a temp: of increased in within the
36.5-37.5 temperature normal range
V/s taken as causes fluid with a temp: of
follows: loss such as 36.5-37.5
Temp: 38.2 sweating
PR-80
RR-20
BP-120/80
-provided
surface cooling -to promote
such as TSB core cooling by
and removing helping
of extra reduced body
clothing temperature

Dependent:

Give
paracetamol Paracetamol
(biogesic) as are classified
prescribe by as analgesics
the physician and
antipyretics
which acts on
the
hypothalamus
to regulate
normal body
temperature
 Discharge plan
DISCHARGE PLANNING

Discharge Planning Diet:

Encourage nutritious foods like vegetables, meat and fruits.> Instruct the family members to give the
client protein rich foods such as meat, fish, eggs and nuts, vitamin K rich foods such as green leafy
vegetables, vit C rich foods(guava and tomatoes and other citrus fruits), carbohydrates rich food (breads
and rice)

Medications:

Give acetaminophen in case the temperatures increases.

Give oresol to replace fluid in the body.

Remind to take the prescribed medicine, having a written reminder of the correct medication, time to
take, and the right frequency of the medicine on the way home to establish assurance of medication
compliance.

Don’t give aspirin and NSAID’s, they increase the risk of bleeding. Any medicines

That decrease platelet count should be avoided.

Exercise:

Instruct to avoid excessive activities that may result to stress. Just advised to perform range of motions
and repetitive body movements for promotion of optimum

Treatment:

Currently, no medications are available to treat dengue hemorrhagic fever.

> Increased oral fluid intake.

>Admission to an intensive care unit>Intravenous fluids and electrolytes

>Oxygen therapy> Transfusions of blood and platelets as needed> Bed rest Out-Patient Follow-Up Care
>Instruct the family members to have a check-up or to consult physician once a while to monitor

patient’s condition and for detection of recurrences and other complications that may arise on to

it. Health Teaching: (for prevention)> D- discuss the possible source of infection of the disease.> E-
educate the family/patient on how to eliminate those vectors.> N- Never stocked water in a container
without cover.> G- Gallon, container and tires must have proper way of disposal.> U- Use insecticides at
home to kill or reduce mosquito

Bibliography

books

 Principles of Anatomy and Physiology

Gerard J. Tortora (Author), Bryan H. Derrickson
 Laboratory Manual for Anatomy and Physiology[Spiral-Bound]
Connie Allen (Author), Valerie Harper (Author)
 Nurse's Pocket Guide (NANDA) 11th Edition

Google
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