CASE STUDY (DENGUE)

IntroductionDengue: Caused by Flavivirus that is being carried

by a female “Aedes Aegypti” which can cause Fever that can lead to Hemorrhagic Fever.

“Aedes”= UnusualThe mosquito originated from Africa that is characterized by Stripes in the body and legs.*Male mosquitoes does not bite, they dont feed on blood*

Mosquitoes live in clean waterAedes Eagypti can only live in 1cc of clean water

Dengue is very common in the TropicsThe earliest recorded incident was in the Jin

dynastyThey tagged it as Water Poison caused by flying

insectDengue was also know as breakdown fever (1789)

Patient profileName: Agapito, Jerome Patrick BueneveturaAddress: 033 Brgy. Kaypian CSJDM, BulacanAge: 12 y/oBirthday: December 14, 1996Sex: MaleMarital Status: SingleReligion: Roman CatholicNationality: FilipinoAdmission Date: August 17, 2009Ward: Pedia

Physical Assessment 1. Skin -skin color -varies from light to deep brown -presence of edema-no edema -presence of red rashes from knees to toes both

extremeties-abnormal -skin temperature-within normal range -skin turgor-when pinched, skin springs back to previous state 2. hair -evenness of growth over the sculp -evenly distributed hair -hair thickness or thinness - thick hair -hair texture and oiliness -silky, resilient hair -presence of infections or infestation - no infection or infestation -amount of body hair -variable 3. skull and face -size, shape and symmetry of the skull -rounded (normecephalic

and symmetric, with frontal, parietal, and occipital prominencies -nodules or masses and depressions -absence of nodules and

masses -facial features -symmetric facial features -symmetry of facial movements -symmetric facial movements

4. eyes -eyebrows - hair evenly distributed; skin intact -eyelashes -equally distributed; curled slightly outward -eyelids -skin intact; no discharge; no discoloration -bulvar conjunctiva -transparent; capillaries evident;

sclera appears white -palpebral conjunctiva -pinkish5. ears -color -color same as facial skin -symmetry of size -symmetrical -external ear for cerumen, skin lesions, pus or blood -

clean external ear6. nose -color -uniform color -deviations, shape and size -symmetric and straight -flaring or discharge from the nares -no discharge or

flaring -determine any areas of tenderness, masses and

displacement of bone and cartilage -no tender; no lesions -determine potency of both nasal cavities -air moves

freely as the client breathes through the nares

7. mouth =LIPS -color -dark -texture -soft, moist, smooth texture =TEETH -color -white -distribution -no missing teeth =GUMS -color -pinkish -texture -moist, firm texture =TONGUE -position -central position -color -pink color -texture -smooth, lateral margins; no lesions -movement -moves freely; no tenderness8. neck -position -head centered -head movement -coordinated, smooth movement

with no discomfort

9. thorax -symmetry -chest symmetric -spinal alignment -spine vertically aligned -spinal column -spinal column is straight shoulders and hips -right and left shoulders

and hips are at the same height10. abdomen -skin integrity -unblemished hair -color -uniform color

PathophysiologyFlavivirus flavivirus↓ ↓(Aedes aegypti) Platelets↓ ↓Human ↓ bloodclotting↓ ↓bone invasion bleeding↓Activate immune response↓Fever

Anatomy and PhysiologyDuring the infxn of dengue the most commonly

affected among all body system is the circulatory systems, most specially to the blood components since during the transfer of virus it used blood feeding with the use of the mosquitoes saliva . Now with this blood feeding process of the mosquito there is greatly an alteration in the blood systems and there is more probably destruction in the homeostesis the most commonly thing to do during a diagnosis of dengue is the platelet counting. It determines the probability of having a hemorrhagic effect on the patient and the WBC as well as it fights for infxn.

Circulatory system is an organ system that transports nutrients, blood gases, hormones, blood cells, waste product, etc. To and from cells in the body to help fight diseases and help stabilize body temperature and ph to maintain homeostasis....

Blood –( life giving of the body.)Plays an important role in maintaining homeostasis in a living organism.

FUNCTIONS OF BLOOD (TPR) 1. TRANSPORT 2. PROTECTION 3. REGULATION PHYSICAL PROPERTIES OF BLOOD 1. AVERAGE ADULT 7-9% of total body weight male 5-6 liters of blood female 4-5 liters of blood 2. Red color of arterial blood is due to oxygenated hemoglobin (Hgb)

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

1.Plasma – liquid portion of blood, made up off the ff: A. Water – 90%, provides the solvent for dissolving and transport of nutrients. B. Plasma proteins – synthesized mostly by hepatocytes (liver cells) I. Albumin - water retention in the blood to maintain blood volume and pressure. II. Globulins – acts as carrier molecule to transport liquid and fat soluble vitamin in the blood. - used as antibodies – immunoglobulin III. Fibrinogen – for blood clotting SERUM = plasma minus fibrinogen and other protein involved in clotting.

2. Formed elements – whole cell, cell fragments.

A. RBC – red blood cells – erythrocytes

From greek erythros for “red” and kytos for “cell” transport O2 removes CO hemoglobin (red color) life span 120 days or 4

months

B. WBC – white blood cell- leukocyte

derived from greek leukos( white ) and kytos(cell) soldiers of the body engulf micro organism

Types of WBC1.Granular leukocyteHas granules in the cytoplasma. Neutrophilb. Eosinophilc. Basophil 2. AgranularNo granulesHave unsegmented nucleusa.Lymphocyteb.monocyte

GRANULARA. Neutrophil 10- 12 diameter Main target bacteria and fungi Nucleus multi lobes Fine,faintly pink

B.Eosinophils 10-12 diameterMain target parasites and in allergic re actions full of pink Granules contains lysozymes’ peroxidase to destroy intruder.

C. Basophil 12-15 diameter main target in allergic reaction large blue

AGRANULARA.LYMPOCYTES 7-8 Diameter1.B cell2.T cell3.NK cellsSecond most abundant leukocytesGrouds slightly indented nucleusProduced antibodiesSeen in acute viral infections and chronic bacterial infections.

B. Monocytes Kidney shaped nucleus largest formed elemments stay in the blood stream only for 3 days

C. PLATELETS THROMBOCYTES150,000-400,000 cell of bloodDisk shaped cell fragmentsNo nucleus Life span 7-8 daysPromote blood clotting

Coarse in the ward COURSE IN THE WARD Jerome Patrick Agapito, a 12yr old boy, was admitted at Kairos

Maternity and General Hospital on August 18, 2009 at 11:00am. With chief complaint of skin rashes under the service of Dr. Mendoza. After secured consent for admission was done.

The patient was endorsed in the ward from Emergency Room, accompanied by his mother per wheelchair, with ongoing IVF of D5LR 1L at 900cc level regulate at 20-21 gtts/min. Complete blood count with after meals done and relayed. The patient was on diet as tolerated except dark

colored foods. Still for urinalysis to secure result. In every 4hours vital signs was taken and recorded. In addition, nurses was instructed the mother of the patient to increase oral fluid intake. Includes, nurses continuous watch out for signs of bleeding.

On August 19, 2009 at 12:00pm, due oral medicines given as the doctor's ordered such as ; omeprazole 20mg 1tab given, ceftrizine 1omg 1tab given, pedzine with vitamin C 1tbsp. and paracetamol 500mg 1 tab. Afterwards, urinalysis done with result. The nurse observes the patient with flushing of skin but absence of nose and gum bleeding.

At 8:00am, Dr. Mendoza with orders made and carried out Aquamephyton 10mg given for run every 5hrs. IV push. Nurses still watch out for any signs of bleeding, and continuous giving of care to the patient.

Nursing Care Plan Assessment Diagnosis Background knowledge Planning

Subjective:“Nilalagnat ang apo ko at may mga rashes siya sa paa at hinang hina na siya” as verbalized by the patient’s grandmother.Objective:Temp.= 37.4BP= 100/90PR= 72RR= 19>presence of rashes>rubor >weakness and fatigue

Activity Intolerance r/t exhaustion associated with alteration in physiological pattern as manifested by weakness and fatigue

Dengue↓

Increase body metabolism

↓Weakness and Fatigue

↓Activity Intolerance

After 8 hrs of NI the pt. will be able to demonstrate increase in activity of daily living

Intervention Rationale Evaluation

1. Evaluate pt’s response to activity. Note increased weakness and fatigue2.Monitor VS regular and note changes in VS during and after activities3.Provide a quiet environment and limit visitors during acute phase as indicated4.Encourage use of energy saving techniques5. Explain importance of rest in treatment plan and necessity for balancing activities with rest6.Assist pt. to assume comfortable position for rest or sleep 7. Assist with self care activities as necessary

1. Establishes pt’s capabilities/ needs and facilitates choice of intervention2.Helps the pt. nurse assess the pt’s condition and identify appropriate condition 3.Reduces stress and helps patient rest4.Helps the pt. conserve energy for healing 5.Helps decrease metabolic demands and hasten recovery6.Promotes good rest and sleep for the pt.7.Minimizes exhaustion and prevent untoward incidents from happening

After 8 hrs of NI the pt. was able to demonstrate measurable increase in activity tolerance and was able to perform some activity of daily living

Drug StudyGeneric Name Brand Name Dosage &

FrequencyRoute Classification

1. Omeprazole2. Cetirizine3. Paracetamol4. Phytonadione

- Losec, Prilosec- Reactine, Zyrtec- Abenol,

Acephen, Aceta, Acetaminophen, Actamin, Aminofen, Atasole, Bamasin, Dapa, Dymadon, Dymadon P, Exdol, Feverall, Genapap, Genebs, Liquipirin, Neopap, Oraphen-PD, Panadol, Panamax, Paralgin, Tylenol, Tempra, Valorin

- Aquamephyton

20mg/tab OD10mg/tab OD

500mg/tab q4h10mg/ml STAT

POPOPOIV

Gastro intestinal agentProton pump inhibitorAntihistamine; H1 Receptor antagonistAnti pyreticSynthetic vitamin; antedote

Action Indications Contraindications Side Effects Nursing Considerations

1) Suppresses gastric acid secretion by inhibiting the H+, K+ -ATPase enzyme system (Proton H+) in the parietal cells.

2) Potent H1 receptor anti-histamine without significant anti cholinergic or CNS activity. Low lipophilicity combined with its H1 receptor selectivity probably accounts for its relative lack of anti cholinergic and sedatives properties.

3) Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in CNS or other substances that sensitize pain receptors to stimulation.the drug may relieve fever through central action in hypothalamic heat regulating center,

4) An anti-hemorrhagic factor that promotes hepatic formation of active coagulation factors

- Duodenal & gastric ulcers. Gastroesophageal reflux disease including severe erosive esophagitis. Long term tx of pathologic hypersecretory conditions such as Ellison syndrome, multiple endocrine adenomas & systemic mastocytosis. In combination with claritromycin to treat duodenal ulcers associated with Helicobacter pylori

- Seasonal and perennial allergic rhinitis and chronic idiopathic urticaria.

- Mild pain or fever

- Hypoprothrombinemie caused by vitamin K malabsorption, drug therapy or excessive vitamin A dosage

- Hypoprothrombinemie caused by effects of oral anticoagulants

- To prevent hemorrhagic disease of newborn

-

hemorrhagic disease of newborn

- Contraindicated in long term use for gastroesophageal reflux disease, duodenal ulcers, lactation.

- Contraindicated in hypersensitivity to H1 receptor anti-histamine.

- Contraindicated in patients hypersensitive to drugs

- Use cautiously in patients with long term alcohol use because therapeutic dose causes hepatotoxicity in these patients.

- Containdicated in patients hypersensitive to drugs.

- CNS : Headache, dizziness, fatigue.

- GI: Diarrhea, abdominal pain, Nause, mild transient, ↑ In liver function test

- GU: Hematuria, Proteinuria

- OTHERS: Rash

- CNS: Drowsines, sedation, headache, depression

- GI: Constipation, diarrhea, dry mouth.

- Hematologic: hemolytic anemia, neutropenia, leukopenia, pancytopenia.

- Hepatic: jaundice- Metabolic: hypoglcemia- Skin: rash, urticaria

- CNS: headache, weakness

- EENT: staining of teeth- GI: gastric distress- OTHER: hypersensitivity

reactions.

- Capsules must be swallowed whole & should be taken before eating.

- Monitor urinalysis for hematuria & proteinuria

- Instruct to report any changes in urinary elimination such as pain or discomfort

- Instruct to report severe diarrhea. The drug may

- need to be discontinued

- As the drug is highly protein bound, the potential for interaction with other protein bound drugs exist.

- Monitor for sedation especially the elderly.

- Caution to determine response to drug before engaging in hazardous activities.

- Many OTC & prescription products contain acetaminophen; be aware of these when calculating daily dose

- Use liquid form for children & patients with difficulty of swallowing

- In children don’t exceed 5 doses in 24 hours

- Give oral drops undiluted or mixed with fluids of foods. Avoid simultaneous ingestion of dairy products.

- Chronic toxicity may result from prolonged use of higher than recommended dose.

Discharge planning D – Diuretics and vitamins supplement must be taken

appropriately to increase protection mechanism of the immune system.

E – Eliminate vector by promoting cleanliness in the environment through proper disposal of possible breeding sites.

N – Never underestimate the power of the mosquitoes. Observe for signs & symptoms after being stung.

G – Guide and encourage the family members in the proper prevention of DENGUE.

U – Use of non pharmacotheraphy such as drinking lots of water that will promote increase in plasma in blood and increase immunity.

E – Eat foods that are non fat, no carbonated no irritating and low in fiber.

Laboratory all result with interpretation

Normal Value Result   RBC Female 4.0- 4.5 4.4 Male 4.5- 5.0   Female 120- 140 Hgb Male 130- 160 143   Female 37- 47 0.42 Hct Male 42- 52   WBC 5.0- 10.0 6.8   Erythrocyte Female 0- 20 80 Sedimentation Male 0- 9 Rate   Platelet Count 140- 340

  August 19,2009   Female 4.0- 4.5 4.39 RBC Male 4.5- 5.0     Hgb Female 120- 140 139 Male 130- 160   Hct Female 37- 47 0.41 Male 42- 52   WBc 5.0- 10.0 7.2   Erythrocyte Sedimentation Female 0-20 89 Male 0-9 Rate