Republic of the Philippines
CENTRAL MINDANAO UNIVERSITY
COLLEGE OF NURSING
University Town, Musuan, Maramag, Bukidnon
E-mail: nursing@cmu.edu.ph
A Case Presentation of a Child with Grade 1Dengue Fever
A Case Study Presented to the Faculty of the College of Nursing,
Central Mindanao University
In Partial Fulfillment of the Requirements in
NCM 66.1: MATERNAL AND CHILD AT RISK OR WITH PROBLEMS
(ACUTE AND CHRONIC)
BSN 2 – B
GROUP 2
Santos, Lea Marie Khristine I.
Orate, Eula Marie Victoria V.
Sabornido, Jastine Nicole B.
Dominguez, Ann Mariz U.
Gauran, Rogelen May A.
Tulang, Ana Domini B.
Manlangit, Kint D.
Balcos, Andrea A.
Andrada, Leah S.
Chu, Abrey Mia
CLINICAL INSTRUCTORS
Postrano, Fave Danielle, RN
Postrano, Lharra Mae, RN
Luceño, Hanely Mae, RN
Itable, Emvie Loyd, RN
APRIL 2021
Acknowledgement
The researchers would like to extend their deepest gratitude to the people
who contributed and supported this study to be promising and fruitful;
To their group’s Clinical Instructor, Ms. Fave Danielle V. Postrano, RN, for her
valuable time and effort in suggestions, corrections, and inputs for the development
of the case study;
To the Clinical Instructors of Central Mindanao University, College of Nursing,
for inputs, comments, and suggestions for the case study; and
To the Almighty God for blessing and giving the researchers strength to
conduct, analyze, and finish the paper.
The Researchers
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Table of Contents
Page
PRELIMINARIES
Acknowledgement
Table of Contents
INTRODUCTION
Definition
Clinical Pathway
Statistics
Objectives
HEALTH HISTORY
A. Biographical Data
B. Reason for Seeking Health Care/Chief Complaint
C. History of Present Illness
D. Past Medical History
E. Personal History
F. Hospitalization History
G. Immunization History
H. Family Genogram
I. All Content of Health History
PHYSICAL ASSESSMENT
DEVELOPMENTAL MILESTONE OR STAGES
A. Developmental History
DEVELOPMENTAL THEORIES
ANATOMY AND PHYSIOLOGY
CONCEPT MAP
A. Schematic Diagram
B. Narrative Discussion
a. Etiology
b. Pathophysiology
c. Symptomatology
d. Prognosis
LABORATORY & DIAGNOISTIC TESTS
MEDICAL MANAGEMENT
A. Pharmacotherapy, Intravenous Fluids & Nursing
Responsibilities
B. Diet & Activity Management & Nursing Responsibilities
SUMMARY OF MEDICAL MANAGEMENT
A. Pharmacotherapeutics
B. Intravenous Fluids
NURSING CARE PLAN
A. Problem List (Summary)
REFERENCES
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Introduction
Definition
Dengue is a viral infection characterized as a severe, flu-like illness caused
by four different serotypes of a flavivirus named DENV1-DENV4 (Elling et al., 2013).
The World Health Organization classifies it into two major categories: dengue
(with/without warning signs) and severe dengue.
The virus is transmitted to humans through bites of infected female
mosquitoes of the Aedes genus, mainly the Aedes aegypti and the Aedes albopictus.
Symptoms of dengue usually last for 2-7 days, after an incubation period of 4-10
days after the bite from an infected mosquito (WHO, 2020). Mosquitoes can also
become infected by people who experience symptomatic, pre-symptomatic, or even
asymptomatic dengue infections. The extrinsic incubation period (EIP) takes about
8-12 days and is influenced by several factors such as ambient temperature (2528°C), the magnitude of daily temperature transmissions, virus genotype, and initial
viral concentration. Once infectious, the mosquito can transmit the virus for the rest
of its life (WHO, 2020).
Although the primary mode of transmission for the disease involves
mosquitoes as its vector, there is evidence of the possibility of maternal
transmission. When a mother does have a DENV infection when pregnant, babies
may suffer from pre-term birth, low birth weight, and fetal distress (WHO, 2020).
Clinical Pathway
Dengue fever may be considered if the client manifests fever for ten days or
less accompanied by the following symptoms: myalgia, arthralgia, bone pain,
headache, peri-orbital pain, flushing, nausea, or vomiting without symptoms of
respiratory tract infection or organ-specific symptoms of other infectious diseases.
Upon assessment duration of the client’s fever must be obtained. If fever is present
for three days or less, a tourniquet test should be performed with CBC. If a client is
experiencing fever for 4-10 days, CBC is performed. A tourniquet test may also be
performed but is not recommended if the client’s platelet count is less than 80,000
cells/mm³ or if spontaneous petechiae are present. In severe vomiting,
hepatomegaly, or pregnancy, blood test for AST and ALT may be considered. Clinical
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manifestation must also be assessed for warning signs such as persistent/severe
vomiting, abdominal pain or tenderness, hepatomegaly. If the client manifests
warning signs, it is an indication for hospitalization. Clients may be discharged and
provided outpatient care for clients without warning signs with a fever of fewer than
three days. For those without warning signs but with a fever of 4-10 days, the client
must be observed for signs and symptoms of dengue fever and plasma leakage
syndrome. These are also indications for hospitalization. Depending on the
physician’s decision, some symptoms may also be considered for admission to the
hospital (e.g., severe hemorrhage, platelet ≤ 20,000/mm³, renal failure, liver
failure).
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Statistics
Global
According to the World Health Organization, dengue is the most rapidly
spreading mosquito-borne viral disease globally. This disease is now endemic in
more than 100 countries in Africa, the Americas, the Eastern Mediterranean,
Southeast Asia, and the Western Pacific, putting about 40% of the world’s
population at risk of acquiring such disease. The America, South-East Asia, and
Western Pacific regions are the most seriously affected, with Asia representing
~70% of the global burden of the disease. Data from the European Centre for
Disease Prevention and Control reported that Brazil, Vietnam, the Philippines,
Nicaragua, and Peru are the countries with the most dengue cases. In 2020, dengue
continued to affect several countries, with reports of increases in the numbers of
cases in Bangladesh, Brazil, Cook Islands, Ecuador, India, Indonesia, Maldives,
Mauritania, Mayotte (Fr), Nepal, Singapore, Sri Lanka, Sudan, Thailand, TimorLeste, and Yemen.
Data from the WHO states that there are around 390 million dengue virus
infections per year, causing 20 to 25,000 deaths, most of which are children. The
number of cases reported significantly increased 8-fold (800%) over the last two
decades, from 505 430 cases in 2000 to over 2.4 million in 2010 and 4.2 million in
2019. The year 2019 was recorded as the year with the most significant number of
dengue cases ever reported globally.
National
In 2019, the Philippines reported 429,409 cases, including 1,607 deaths - this
is about 170% higher than data reported during the same period in 2018, with
241,707 deaths, including 1,210 deaths. Based on the Department of Health’s 2019
Monthly Dengue Report for Morbidity Weeks 1-35, the majority of the cases
reported were from Region VI (45,436), IV-A (39,810), X (19,925), III (19,088),
and NCR (18.136). Regions IX (430%), VI (375%), VIII (329%), V (243%), and XII
(215%) were the regions with the highest percent increase in the number of cases
compared to the previous year. The majority of the reported cases were male and
belonged to the 5-9 years age group. DENV3 is the most predominant serotype
among the confirmed dengue cases, followed by DENV1, DENV2, DENV4, and mixed
serotype. Most reported deaths were female, and the majority belonged to the 5-9
years age group. Places with the highest number of deaths were Iloilo, Negros
Occidental, Cebu, Zamboanga del Sur, and Cavite.
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In week 9 of 2021, 171 dengue cases were reported in the Philippines.
Furthermore, as of March 6, 2021, 13,699 dengue cases have been reported,
including 50 deaths- this is 68% lower than the 42,584 cases reported in the same
period in 2020.
Objectives
General
This case study aims to showcase the student’s knowledge regarding the
general health and disease condition of a patient with diagnosis, its disease process,
possible complications, treatment plan, medical and nursing intervention, and
necessary nursing interventions with a positive attitude render effective nursing
care.
Specifically, it aims to:
1. Systematically present the data pertinent to the case being gathered;
2. Present personal, clinical, and developmental information of the client, which will
serve as the baseline information;
3. Perform a comprehensive health assessment, and note of the abnormal findings
that may contribute to client’s diagnosis;
4. Recognize the contributing factors associated with the development of the diagnosis;
5. Understand the pathophysiology and etiology of dengue and discuss abnormalities in client’s specific body system affected by the disease, including the prognosis;
6. Identify the necessary diagnostic test and be able to interpret results to confirm
the diagnosis and provide necessary care;
7. Understand the role of drug therapy in managing the client related to the patient’s diagnosis; and
8. Efficiently provide an appropriate and proper nursing diagnosis related to client’s
medical condition and skillfully formulate nursing care plans for the problems
identified.
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Health History
A.
Biographical Data
Patient Code
:
JXDN
Age
:
12- years old
Sex
:
Male
Religion
:
Roman Catholic
Civil Status
:
Single
Address
:
P-3, Poblacion, Valencia City, Bukidnon
Admission Date and Time :
March 15, 2021 at 10AM
Attending Physician
:
Dr. Macarat
Impression/ Diagnosis
:
Fever and Vomiting
Height
:
140 cm
Weight
:
34 kg
BP
:
90/60 mmHg
RR
:
24 bpm
PR
:
120 bpm
Temperature
:
38.6°C
Vital Signs
B.
Reason for Seeking Health Care/Chief Complaint
Fever and Vomiting
C.
History of Present Illness
Five days PTA:
JXDN experienced an intermittent, undocumented fever; no vomiting, no
cough and colds, and no loose stools were noted.
Two days PTA:
JXDN still has no cough and colds, no vomiting, nor loose stools. Fever was
still present and experienced abdominal pain in the epigastric area. The patient
sought a consult at Valencia Medical Center. His Complete Blood Count (CBC) results
were the following: Hgb: 112, Hct: 0.27, WBC: 3.7, and Platelet: 125. The patient’s
initial diagnosis was Urinary Tract Infection (UTI). He was given Cefalexin with an
unrecalled dose and Paracetamol (250 mg) before being discharged.
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One-day PTA:
JXDN was still experiencing fever and epigastric pain, accompanied by vomiting of three episodes with 1cc per episode. There are still no reports of cough and
colds, no loose stools.
Day of Admission:
JXDN was still experiencing fever, epigastric pain, and vomiting, which
prompted the consult. He was ordered for a CBC at the AMCV, and the results were
the following: Hgb: 146, Hct:43, WBC: 5.2, Platelet: 97. He was advised for admission.
D. Past Medical History
No history of asthma, allergies, and primary complex. Also, with no known
allergies to food and medications.
E. Personal History
Mother’s Age
: 25 –years old
G :3
Birth Weight
: Unrecalled
P :2
Type of Delivery
: Caesarean section
Age of Gestation
: Preterm (unrecalled AOG)
P :2
Place of Delivery
: Hospital by an OB-GYN
A :1
Maternal Complication
: Pre-eclamptic during delivery
L) : 2
Fetal Complication
: Jaundice (resolved after a week)
(T : 0
Mother was a non-smoker, non-drinker, and have had regular prenatal checkups beginning month 1 of pregnancy. Mother took unrecalled Multivitamins.
APGAR score was good and baby had a good cry after delivery. Vitamin K
and eye care were given and a newborn screening was done.
Breastfeeding
: 1 ½ years
Formula Milk
: Nestogen and Bona (6- years old)
Complementary Feeding
: 5 months
24- hour Diet Recall
: Rice and adobo for breakfast
: Rice and pork sinigang for lunch
: Fried fish and monggo for dinner
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: Morning snack was bread and milk
Patient’s preference for chicken, pork, beef and squash and regularly consumes soft drinks and junk food for snacks.
F. Hospitalization History
Hospitalized for Acute Gastroenteritis in 2012 and undergone incision and
drainage of a Neck abscess in 2011.
G. Immunization History
BCG (1), DPT (3), OPV (3), HiB (3), Hepa B (4) MMR (2), measles (1)
Rotavirus (0), Pneumococcal (0), Influenza (0) Varicella (0), Hep A (0) and Typhoid
(0).
Patient has not yet had boosters for Hep B, DTaP and MMR.
H. Family Genogram
I. General Health History
Patient JXDN is a 12-year old male residing at P-3, Valencia City, Bukidnon,
and Roman Catholic. He went to the hospital with his father with chief complaints
of fever and vomiting.
Upon assessment, the patient stands 140 cm, weighing 34 kg, and his BMI
was 17.3. His blood pressure runs 90/60 mmHg, respiratory rate of 24 cpm, pulse
rate of 120 bpm, and temperature of 38.6°C. The patient presented himself awake,
alert, and not in cardiorespiratory distress but is weak-looking.
Five days before admission, patient JXDN experienced an intermittent,
undocumented fever; no vomiting, no cough and colds, and no loose stools were
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noted. Two days before admission, patient JXDN still has no cough and colds, no
vomiting, nor loose stools. Fever was still present and experienced abdominal pain
in the epigastric area. The patient sought a consult at Valencia Medical Center. His
Complete Blood Count (CBC) results were the following: Hgb: 112, Hct: 0.27, WBC:
3.7, and Platelet: 125. The patient’s initial diagnosis was Urinary Tract Infection
(UTI). He was given Cefalexin with an unrecalled dose and Paracetamol (250 mg)
before being discharged.
Moreover, one day before admission, patient JXDN was still experiencing
fever and epigastric pain, now accompanied with vomiting of three episodes with
1cc per episode. Furthermore, there are still no reports of cough and colds, no loose
stools. On the day of admission- March 15, 2021, JXDN was still experiencing fever,
epigastric pain, and vomiting, which prompted the consult. He was ordered for a
CBC at the AMCV, and the results were the following: Hgb: 146, Hct:43, WBC: 5.2,
Platelet: 97. He was then advised for admission.
Patient JXDN has no history of asthma, allergies, and primary complexity.
Also, with no known allergies to food and medications.
There is no history of malignancies, diabetes mellitus, hypertension,
atopy/allergies, bronchial asthma, or tuberculosis in the paternal side of the family
for the patient's family history. The patient's mother is hypertensive, and the
maternal grandmother was an ovarian cancer survivor. Overall, there are no other
known heredo-familial illnesses. Patient JXDN has no history of asthma, allergies,
and primary complexity. Also, with no known allergies to food and medications.
JXDN’s personal history shows that he was born a pre-term baby with an
unrecalled age of gestation when his mother was still 25-years old. He was delivered
via cesarean section in a hospital by his mother’s OB-GYN with unrecalled birth
weight. His mother was reported to be pre-eclamptic during delivery, and he
experienced jaundice, but the problem was resolved after one week postpartum.
Before patient JXDN, his mother already had two pregnancies, but one was aborted.
His mother was a non-smoker, non-drinker, and have had regular prenatal checkups beginning month 1 of pregnancy. Mother took unrecalled Multivitamins. Patient
JXDN’s APGAR score was good, and the baby had a good cry after delivery. Vitamin
K and eye care were given, and a newborn screening was done after the delivery.
The patient was breastfed for 1½ years. Complementary feeding started
when the patient was already five months old. Nestogen and Bona formula milk was
given to the patient until he was 6-years old.
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In his 24-hour diet recall, the patient consumed rice and adobo for breakfast,
rice and pork sinigang for lunch, fried fish and monggo for dinner, and bread and
milk for his morning snacks. The patient has preferences for chicken, pork, beef,
and squash and regularly consumes soft drinks and junk food for snacks.
Patient JXDN was hospitalized for Acute Gastroenteritis in 2012 and
underwent incision and drainage of a neck abscess in 2011.
Patient JXDN’s immunization history showed that he already had the
following vaccinations: one shot of BCG, three shots of DPT, three shots of OPV,
three shots of HiB, four shots of Hepa B, two shots of MMR, one shot for Measles,
none for rotavirus, pneumococcal, influenza, varicella, Hepa A, and Typhoid.
Furthermore, he has not yet had boosters for Hepa B, DTaP, and MMR.
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Physical Assessment
Date: March 15, 2021
Time: 10:00am
System/Area
GENERAL
APPEARANCE
Blood pressure
Heart Rate
Respiratory Rate
Temperature
Skull
Head
Face
Neck
Eyes
Findings
Implications
Weak-looking.
Pt. Weakness and fatigue are
complaints of fever and common during the acute
vomiting.
stage of dengue. Fever is a
primary symptom of dengue
while vomiting is included in
the most common symptom of
dengue fever.
VITAL SIGNS
BP: 90/60 mmHg
Normal findings.
HR:
120
bpm In almost all cases, tachycar(tachycardia)
dia in children is caused by a
secondary problem outside
the heart, like a fever or a disease that is caused by a viral
infection, for example dengue
fever.
RR:
24
bpm Majority of the pediatric pa(tachypnea)
tients shows respiratory distress such as tachypnea as a
sign for dengue hemorrhagic
fever.
T: 38.6 C (hyperther- A high fever is one of the primia)
mary symptoms of dengue
that appears three to 15 days
after the mosquito bite.
HEAD AND FACE
Normocephalic
Normal findings.
No lesions in scalp
Normal findings.
Flushed face.
A flushed face is a fairly common symptom of mild to moderate dengue fever.
No neck vein engorge- Normal findings.
ment.
Anicteric sclerae, Pink Normal findings.
palpebral conjunctivae,
o eye discharge, No periorbital edema, No
matting of eyelashes,
Eyes are briskly reactive to light, (+) Red
orange reflex
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System/Area
Ears
Nose
Mouth
Teeth
CARDIOVASCULAR
SYSTEM
CHEST AND LUNGS
BACK AND SPINE
Findings
Ears are symmetric. Ear
canal is non-hyperemic
and
tympanic
membrane
is
not
bulging.
No
tragal
tenderness.
Visible
cone of light bilaterally,
with brownish retained
cerumen
partially
occluding
the
ear
canals bilaterally
Nasal Bridge is flat, no
alar
flaring,
nasal
septum is midline, and
turbinates are pink with
no
watery
nasal
discharge
Dry lips, moist oral
mucosa,
hyperemic
buccal mucosa and
pharyngeal walls. No
tonsillar- enlargement.
No
gingival
and
mucosal lesions
Implications
Normal findings.
Normal findings.
Dry lips mean that the patient
is dehydrated. Patients with
dengue
infection
are
susceptible to dehydration as
a consequence of high fever,
nausea, vomiting, anorexia
and diarrhea during the febrile
phase of 4 to 6 days.
Dental carries present
Dental carries may be caused
by consuming soft-drinks and
processed foods like junk
foods regularly. Patients who
are suffering from dengue
symptoms should avoid these
types of foods.
Adynamic precordium, Normal findings.
No heaves no thrills,
Regular cardiac rate
and rhythm, Distinct
heart sounds s1>s2 at
the base, Apex beat at
the 4th ICS MCL, No
murmurs appreciated
Symmetric
chest Normal findings.
expansion,
No
retractions, No lesions
or masses, Clear breath
sounds
No lesions and obvious Normal findings.
spinal deformities
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System/Area
ABDOMEN
Skin
Nails
Extremities
LEVEL OF CONSCIOUSNESS
Findings
Implications
Flat abdomen, no dis- Epigastric tenderness or abtention, no scars, no dominal pain is a common
masses, normoactive symptom (40%) in dengue inbowel sounds and fections and is more comtypanitic on all quad- monly associated with dengue
rants, with epigastric hemorrhagic fever (DHF).
tenderness
(pain
scale= 5/10) but no organomegaly on palpation.
INTEGUMENTARY SYSTEM
Negative
tourniquet Normal findings.
test, no obvious deformities, no rashes, no
lesions, and no cyanosis.
No
clubbing. Normal findings.
CRT<2secs
Full range motion of Normal findings.
upper
and
lower
extremities on active
and passive motion
Glasgow Coma Scale: Normal findings.
15, Cranial Nerves testing not done.
Page 15 of 60
Developmental Milestone or Stages
A.
Developmental History
Infant - Up to 1 year:
At the age of 10 months, the patient can stand on his own.
Toddler - From 1 year to 3 years:
At the age of 2 years old, the patient can walk upstairs alone and makes
circular strokes.
At the age of 3 years old, most of speech intelligible to strangers, parallel
play, and helps in dressing.
4 to 17 years:
At 12 years old, no noted delay in gross motor, with fine adaptive, social
and language developmental milestones.
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Developmental Theories
Stages
Stage Description
FREUD
ERIKSON
PIAGET
KOHLBERG
HAVIGHURST
(Psychosexual)
(Psychosocial)
(Cognitive)
(Moral Reasoning)
(Developmental Tasks)
The influence of the
sexual desire drive on
the human psyche was
central to Freud's theory
of
personality
formation. He believed
that a single body part is
especially vulnerable to
sexual,
erotic
stimulation at certain
stages of development.
The mouth, genitals,
and genital area are the
three erogenous areas.
The child's libido is
focused on behavior
that affects his age's
primary
erogenous
zone.
He
cannot
concentrate on the
primary erogenous zone
of the next stage
without addressing the
developmental tension
Sigmund Freud's five
phases of development
were expanded into
psychosocial
development
theory.
Erikson claims in his
psychosocial philosophy
that ego identity is
achieved by confronting
goals and problems
during the life cycle's
eight stages of growth.
Each psychosocial stage
is defined by two
conflicting
emotional
powers, referred to as
opposite
dispositions,
which result in a crisis
that must be resolved.
Each problem must be
dealt with as quickly as
possible; otherwise, a
person's psychological
Piaget's
theory
of
cognitive development
is a systematic theory of
human
intelligence's
history
and
development. According
to Jean Piaget's theory
of cognitive growth,
children's
intelligence
evolves.
A
child's
cognitive growth entails
the
acquisition
of
information and the
development
or
construction
of
a
theoretical image of the
environment. Kids go
through several phases
as
their
cognitive
growth is influenced by
their natural abilities
and external activities.
According
to
Kohlberg's
theory,
there
are
three
phases of moral
advancement:
divided into two
stages.
Kohlberg
theorized that people
go through these
stages
in
a
predetermined
sequence and that
moral awareness is
related to cognitive
growth.
Preconventional,
traditional, and postconventional moral
reasoning are the
three levels of moral
reasoning.
According to this
hypothesis, six agespecific life stages
ranging from birth to
old age, each with its
own
set
of
developmental
activities.
Physical
maturation, personal
values, and societal
pressures
all
influenced
Havighurst's
developmental
activities. Accepting
one's body, adopting
a set of values and
an ethical system as
a guide to behavior,
developing healthy
attitudes
toward
oneself as well as
social groups and
Page 17 of 60
Student Nurse’s
Observation
of the current one.
well-being would
jeopardized.
be
Id is present at birth;
voluntary
sphincter
regulation is acquired
with puberty; sexual
drive is channeled into
socially
acceptable
behaviors
such
as
schoolwork
and
athletics.
Having a stable family
life; gaining a sense of
control and free will;
developing trust in one's
own abilities; taking
pride in achievements.
institutions,
developing new and
more
mature
relationships
with
age-mates of both
sexes, and settling
on an appropriate
social role were
among the tasks
identified
by
Havighurst for the
adolescent
period
(13 to 18 years old).
Child learns to express
himself by words and
understands gestures;
becomes more social
and applies rules; and
learns to express and
release feelings through
crying.
Punishment
and
obedient orientation
are followed; moral
reciprocity governs
behavior;
interpersonal
compliance
is
established.
Emotional wellbeing
and
relationships
with family members
are maintained, and
academic
abilities
are established at
school and at home.
Page 18 of 60
Anatomy & Physiology
THE IMMUNE SYSTEM
The immune system is the
body's
biological
defense
system,
known as the second line of defense
within the body. The primary purpose
of the immune system is to identify
body
cells
('self')
from
foreign
materials ('non-self') that enter the
body.
The
immune
system
can
distinguish between the body's tissues
and
outside
substances
called
antigens- this allows cells of the
immune army to identify and destroy
only
those
enemy
antigens.
Identifying an antigen also permits the
immune
system
to
"remember"
antigens the body has been exposed
to so that the body can mount a better
and faster immune response the next
time any of these antigens appear.
The immune system comprises many different cells, organs, and tissues that
combat infection, cellular damage, and disease. Cells of the immune system include
white blood cells, such as macrophages, and T and B lymphocytes. The primary
lymphoid tissues of the immune system are the thymus and the bone marrow.
BONE MARROW
The spongy tissue is found inside the
bones. If the immune system is the police force,
the bone marrow is the police academy because
this is where the different types of immune system
cells are created. All cells of the immune system
are created in the bone marrow from a standard
cell type, called a stem cell. These stem cells later
Page 19 of 60
develop into specific cell types, including red blood cells, platelets (essential for
blood clotting), and white blood cells (important for immune responses). Some of
the stem cells will become a type of immune system cell called a lymphocyte. Two
types of lymphocytes comprise the adaptive immune system — B cells and T cells.
B cells mature in the bone marrow (hence the name “B cell”). Cells that eventually
become T cells travel from the bone marrow to the thymus through our bloodstream, where they mature (hence the name “T cell”).
THYMUS
The thymus is a bi-lobed gland located above the heart, behind the sternum, and between the lungs. The thymus is only active through puberty, then
it slowly shrinks and is replaced by fat
and connective tissue. The thymus is responsible for producing the hormone
thymosin, which aids in the production
of T cells. T cells multiply in the thymus, acquire different antigen receptors, and
differentiate into helper T cells and cytotoxic T cells. The thymus will have produced
all the T cells an individual need by puberty.
After the T and B lymphocytes have matured in the thymus and bone marrow, they then travel to the lymph nodes and spleen, where they remain until the
immune system is activated.
LYMPH NODES
Lymph nodes are tissues full of immune cells. These nodes are located strategically throughout the body. Lymph
nodes tend to be most prevalent in areas
near body openings, such as the digestive
tract and the genital region because this
is where pathogens most often enter the
body. Small, bean-shaped structures that
produce and store cells that fight infection and disease are part of the lymphatic system, consisting of bone marrow,
spleen, thymus, and lymph nodes. Lymph nodes also contain lymph, the clear fluid
Page 20 of 60
that carries those cells to different parts of the body. When the body is fighting
infection, lymph nodes can become enlarged and feel sore.
If the immune system is the police force, lymph nodes are their stations.
Once a pathogen is detected, nearby lymph nodes, often referred to as draining
lymph nodes, become hives of activity. Cell activation, chemical signaling, and expansion of the number of immune system cells occur. The result is that the nodes
increase in size, and the surrounding areas may become tender as the enlarged
nodes take up more space than usual.
Two vessel systems are critical to the immune function of lymph nodes:
Blood vessels — Lymph, a fluid rich in immune system cells and signaling chemicals, travels from the blood into body tissues via capillaries. Lymphatic fluid collects
pathogens and debris in the tissues. Then the lymphatic fluid containing immune
cells enters draining lymph nodes where it is filtered. If pathogens are detected,
immune system components are activated.
Lymphatic vessels — Once filtration is complete, lymph vessels carry this fluid
toward the heart. Depending on where the filtered lymph arrives from; it enters
either the thoracic duct on the left side of the heart or a similar, but smaller duct
on the right side of the heart. The thoracic duct collects lymph from the whole body
except the right side of the chest and head. The lymph from these areas drains to
the smaller duct. From here, the lymph and its immune cells are returned to the
bloodstream for another trip through the body.
SPLEEN
The spleen is the largest internal organ of
the immune system, and as such, it contains a
large number of immune system cells. Indeed,
about 25 percent of the blood that comes from
the heart flows through the spleen on every
beat. It is located in the upper left area of the
abdomen, behind the stomach, and under the
diaphragm. As blood circulates through the
spleen, it is filtered to detect pathogens. Healthy
red blood cells quickly pass through the spleen;
however, damaged red blood cells are broken down by macrophages (large white
Page 21 of 60
blood cells specialized in engulfing and digesting cellular debris, pathogens, and
other foreign substances body) in the spleen. The spleen serves as a storage unit
for platelets and white blood cells. The spleen aids the immune system by identifying
microorganisms that may cause infection.
WHITE BLOOD CELLS
White blood cells are also called leukocytes. They circulate in the body in blood vessels and the lymphatic vessels that parallel the
veins and arteries. White blood cells are on
constant patrol and looking for pathogens.
When they find a target, they multiply and
send signals out to other cell types to do the
same. There are two main types of leukocyte:
Monocytes
The largest type and have several roles. Monocytes are phagocytes with the additional ability to expose foreign substances to the specific
immune system.
Macrophages Patrol for pathogens and also remove dead
and dying cells. Macrophages are phagocytes
that develop from monocytes and specialize
depending on their location. Thus, a macrophage that is located in the connective tissue
is called a histiocyte.
Granulocytes
Mast cells
Granulocytes are leukocytes and are divided
into 3 types:
Neutrophil granulocytes- Phagocytes that infiltrate tissue when attracted to the pathogens
via the influence of chemotaxins.
Eosinophil granulocytes- Granulated phagocytes that become activated by histamine and
are, therefore, particularly active in allergic reactions
Basophil granulocytes- In addition to their
phagocytic function, they have the ability to
release heparin, histamine, and proteases
from their granules
Have many jobs, including helping to heal
wounds and defend against pathogens. It resides in connective tissues and mucous membranes, and regulate the inflammatory response. They are most often associated with
allergy and anaphylaxis.
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Dendritic
Phagocytes in tissues that are in contact with
the external environment. Located mainly in
the skin, nose, lungs, stomach, and intestines
(are in no way connected to the nervous system). Dendritic cells serve as a link between
the innate and adaptive immune systems, as
they present antigens to T cells, one of the key
cell types of the adaptive immune system
cells
Lymphocytes
Lymphocytes help the body to remember previous invaders and recognize
them if they come back to attack again. Lymphocytes begin their life in bone marrow. Some stay in the marrow and develop into B lymphocytes (B cells), others head
to the thymus and become T lymphocytes (T cells). These two cell types have different roles:
B
lympho- They produce antibodies and help alert the T
lymphocytes. Proteins that recognize foreign
cytes
substances (antigen) and attach themselves to
them. Programmed to make one specific antibody. When a B cell comes across its triggering antigen it gives rise to many large cells
known as plasma cells. Each plasma cell is essentially a factory for producing antibody, B
lymphocytes are powerless to penetrate the
cell so the job of attacking these target cells is
left to T lymphocytes.
T
lympho- They destroy compromised cells in the body
and help alert other leukocytes. Cells that are
cytes
programmed to recognize, respond to and remember antigens. When stimulated by the antigenic material presented by the macrophages, the T cells make lymphokines that signal other cells. Other T lymphocytes are able
to destroy targeted cells on direct contact.
PLATELETS
Platelets have been shown to cover a
broad
range
hemostasis,
functions
of
they
and
thus
functions.
have
Besides
immunological
participate
in
the
interaction between pathogen-host defense.
Platelets have a broad repertoire of receptor
molecules that enable them to sense
invading pathogens and infection-induced inflammation.
Page 23 of 60
SKIN
The skin is one of the most
critical parts of the body because it
interfaces with the environment and is
the first defense mechanism from
external
factors.
It
acts
as
an
anatomical barrier from pathogens
and damage between the internal and
external bodily defense environments.
Langerhans cells in the skin are part of the adaptive immune system.
The immune system is made up of two parts. The innate immune system,
provides the body with immediate and general protection from any invading pathogen. The innate immune response rapidly recognizes and responds to pathogens,
but it does not provide a person with long-term immunity against an invading pathogen. The second part is the adaptive immune system, produces cells that specifically and efficiently target the pathogen and infected cells such as: antibodysecreting B cells and cytotoxic T cells. The adaptive immune system takes longer to
respond to an invading pathogen than the innate immune response, but it provides
a person with long-term immunity against a pathogen
When an infected mosquito feeds on a person, it injects the dengue virus
into the bloodstream. The virus infects nearby skin cells called keratinocytes, the
most common cell type in the skin. The dengue virus also infects and replicates
inside a specialized immune cell located in the skin, a type of dendritic cell called a
Langerhans cell. Once the Langerhans cells are infected with the dengue virus, they
travel from the infection site in the skin to the lymph nodes. Langerhans cells display
dengue viral antigens on their surface, which activates the innate immune response
by alerting two types of white blood cells, called monocytes and macrophages, to
fight the virus. Normally, monocytes and macrophages ingest and destroy pathogens, but instead of destroying the dengue virus, both types of white blood cells
are targeted and infected by the virus.
The dengue virus tricks the immune system to get around its defenses and
infect more cells. As the infected monocytes and macrophages travel through the
lymphatic system, the dengue virus spreads throughout the body. During its journey, the dengue virus infects more cells, including those in the lymph nodes and
Page 24 of 60
bone marrow, macrophages in both the spleen and liver, and monocytes in the
blood.
Page 25 of 60
ORGAN AND CELL
Bone Marrow
Thymus
Lymph Node
ILLUSTRATION OF
NORMAL FINDINGS
NORMAL FINDINGS
ILLUSTRATION OF ABNORMAL FINDINGS
ABNORMAL FINDINGS
Bone marrow is made up of
a small number of blood
stem cells, more mature
blood-forming cells, fat
cells, and supporting tissues that help cells grow.
With bone marrow disease,
there are problems with the
stem cells or how they develop.
The thymus changes with
age. Its shape and the proportion of solid tissue and
fat vary between individuals. Thymic density and
volume decreased progressively with age.
Diffuse enlargement of the
gland or a discrete mass.
Many
lesions—including
thymoma, thymic carcinoma, and thymic carcinoids—as well as benign
lesions—such as thymolipomas and cysts—can present
with a focal thymic mass.
Lymph nodes greater than
1 cm in diameter. Hard or
matted lymph nodes may
suggest malignancy or infection.
Normal
lymph
node is
small, approximately 3-7
mm, usually spool-shaped,
smooth, sharply edged,
elastic in consistency, not
fused with the skin or underlying tissues and is not
painful during palpation.
Page 26 of 60
Spleen
WBC
Platelets
Skin
Weighs approximately 200g
and is usually impalpable.
Soft at the midclavicular
line, non-tender, and often
palpable only on deep inspiration.
Splenic tenderness. Enlarged and palpable spleen
>2 cm below the costal
margin. Dullness on percussion beyond the 11th intercostal space suggests
splenomegaly.
For men, a normal white
blood cell count is between 5,000 and 10,000
per μl of blood. For women
4,500 and 11,000 per μl,
and for children, 5,000 and
10,000.
Leukocytosis is an elevation
in the absolute WBC count
(>10,000 cells/μL). Leukopenia is a reduction in the
WBC
count
(<3500
cells/μL).
Smooth platelet. The normal number of platelets in
the blood is 150,000 to
400,000 platelets per microliter (mcL) or 150 to 400
× 109/L.
Spiky platelet. Having more
than 450,000 platelets is a
condition called thrombocytosis;
having
less
than 150,000 is known as
thrombocytopenia.
Uniform skin color, intact,
without
inflammation,
smooth, soft and dry, free
of lesions and without
edema.
Has primary skin lesions,
varied skin color, un-intact,
has inflammation and has
edema.
Page 27 of 60
Concept Map
(Etiology, Pathophysiology, Symptomatology & Prognosis)
A. Schematic Diagram
Page 28 of 60
Page 29 of 60
B. Narrative Discussion
a. Etiology
Dengue fever is a viral infection spread by mosquitos. Female mosquitoes
from the genus Aedes, specifically Aedes aegypti and, to a lesser degree, Aedes
albopictus transmit the infection. Dengue is a single-stranded positive-sense virus
belonging to the Flavivirus genus in the Flaviviridae family. DENV or dengue virus
has four serotypes (DENV-1, DENV-2, DENV-3, DENV-4), which means that a person
can get infected four times. DENV can cause an acute flu-like illness, although most
DENV infections are mild. Extreme dengue fever is a potentially fatal condition that
may occur in some cases (Vittor, 2019; WHO, 2020).
Predisposing Factor
Age
Geographical Area
(Tropical Region)
Present Absent
Although there are cases that
adults can also be infected with
dengue,
possibilities
are,
children are more vulnerable
since they play anywhere,
where breeding sites are
located.
√
√
Pre-existing anti-dengue
antibody either cause by
previous
infection
or
maternal antibody passed
to infants
√
Immunocompromised
√
Precipitating Factor
Environmental conditions
(stagnant water or open
spaces with water pots
and plants
Present Absent
√
Cleanliness
√
Mosquito carrying dengue
virus
√
Implications
Dengue are transmitted by
mosquitoes that are sensitive to
changes
in
rainfall
and
temperature,
transmission
intensity may be regulated by
weather and climate.
Secondary infection increases
the risk of more serious disease
due to antibody-dependent
enhancement (ADE), resulting
in dengue hemorrhagic fever
(DHF)
or
dengue
shock
syndrome (DSS).
Previous infection increases the
risk of severe symptoms if one
gets dengue fever again.
Implications
Stagnant
water
provides
favorable
conditions
for
mosquitos to breed.
Unclean environment will serve
as a breeding ground for
mosquitos.
Dengue spreads where Aedes
aegypti mosquitoes are present.
Page 30 of 60
b. Pathophysiology
Aedes aegypti, a dengue virus carrier, could replicate the virus on its salivary
glands within 8-12 days. When it bites through a person’s skin, the virus then infects
and replicates inside the immunity cells of the skin called Langerhans cells. These
cells will then release interferon to limit the spread of the infection. The infected
Langerhans cells then go to the lymphatic system to alert the immune system.
However, these cells containing the dengue virus will only interfere in the systemic
circulation and be inoculated towards blood circulation. Dengue fever has a 3-14day incubation period (average 4-7 days) after being inoculated into a human host,
during which time the virus replicates in target dendritic cells. Dengue virus is
disseminated rapidly into the blood and stimulates WBCs, including B lymphocytes
that produce and secret immunoglobulins (antibodies), monocytes/macrophages,
and
neutrophils.
The
antibodies
attach
to
the
viral
antigens.
Then,
monocytes/macrophages will perform phagocytosis through the Fc receptor (FcR)
within
the
cells,
and
the
dengue
virus
replicates
in
the
cells
of
monocytes/macrophages. The dengue viral antigen will then be recognized on
infected monocyte by cytotoxic T-cells. The release of cytokines consisting of
vasoactive agents such as interleukins, tumor necrosis factor, urokinase, and
platelet-activating factors stimulates WBCs, and pyrogen release will, later on,
develop dengue fever.
A small percentage of dengue fever individuals can develop a more severe
form of the disease known as dengue hemorrhagic fever (Normandin, 2012). It
occurs when cellular direct destruction and infection of red bone marrow precursor
cells and immunological shortened platelets survive, causing platelet lysis. The
platelet lysis will result in low platelet count or thrombocytopenia and will increase
vascular permeability. This part is where the infected person gets to bruise easily.
Since the permeability has affected, it will also increase the number and size of the
pores in the capillaries, leading to leakage of fluid from the blood to interstitial fluid,
also known as plasma leakage, of the different organs and skins. Bleeding then
follows, then eventually becomes a dengue hemorrhagic fever.
c. Symptomatology
Many people are unaware that they have a dengue infection because they
show no signs or symptoms. Symptoms usually appear four to ten days after being
bitten by an infected mosquito, and it may be mistaken for other illnesses, including
the flu (Mayo Clinic, 2020). Common signs and symptoms of dengue infection
include abdominal pain, bone and joint pain, chills, diaphoresis, fatigue, fever,
headache, nausea, rashes, and vomiting (Stöppler, 2019).
Page 31 of 60
Signs and
Symptoms
Abdominal
Pain
Present Absent
√
Bone and
Joint Pain
√
Chills
√
Diaphoresis
√
Fatigue
√
Fever
√
Headache
Nausea
√
√
Rashes
Vomiting
√
√
Implication
The patient reported abdominal pain in the
epigastric area. The pathogenesis of
epigastric pain in dengue fever is unknown;
however, lymphoid follicular hyperplasia
appears to play an important role, and
plasma leakage via weakened capillary
endothelium has also been suggested.
The acute pain in the joints and bones
causes victims of dengue fever to contort,
hence the term “breakbone fever.” Acute
reactive arthritis during dengue fever is one
of the pains associated with the disease.
Symptoms of dengue fever normally begin
with a rapid and severe rise in temperature,
which can exceed 41°C (105°F) in extreme
cases. Dengue fever is characterized by a
high fever that may be accompanied by
chills or shivering.
Dengue fever causes acute dehydration due
to heavy sweating and internal body
processes. As a result, it's important to
drink plenty of water and fluids to keep the
body hydrated. Dehydration can cause
serious headaches and muscle cramps.
Keeping your body hydrated would also aid
in your recovery.
Fatigue is common during the acute stages
of dengue infection and is defined by the
presence of a persistent sense of
exhaustion that result in a decreased
capacity for physical and mental work.
Dengue fever is characterized by chills
which induces a serious flu-like infection.
The most common symptom of dengue
fever is a sudden and intense increase in
temperature, which can reach 41°C (105°F)
in extreme cases.
Patients of classic dengue fever have a
more moderate headache than patients
with dengue hemorrhagic fever, which is a
more severe variant of the disease.
Nausea is a possible and not so obvious sign
of dengue. This sign is often accompanied
by vomiting.
Cutaneous symptoms are a key indicator of
dengue fever. Patients with dengue fever
who have a skin rash experience itching and
swelling of their hands and soles, but those
who do not have a skin rash have more
symptoms and worse illness outcomes.
While vomiting is associated with various of
diseases, this sign is still one of the possible
warning signs of dengue. Additionally,
vomiting should not be overlooked since
this could also cause dehydration for the
patient.
Page 32 of 60
Moreover, if dengue fever persists, possible symptoms may occur, such as
bleeding, bruising, hypotension, petechiae, and red sclera in both eyes. These
symptoms are leading to hemorrhagic fever, a severe type of dengue.
Signs and
Symptoms
Present
Absent
Bleeding
√
Bruising
√
Hypotension
√
Petechiae
√
Red sclera in
the eyes
√
Implication
You may experience bleeding under your
skin, gums, and nose, as well as vomit
blood or eliminate blood in your stools if
you have dengue hemorrhagic fever.
Bruising easily is one of the possible signs
of hemorrhage when diagnosed with
dengue fever. This type of dengue fever
can be fatal, and it can lead to dengue
shock syndrome, the most serious cause
of the disease.
Extreme dengue shock is basically dengue
hemorrhagic fever that has progressed
into circulatory collapse, resulting in
hypotension, narrow pulse pressure (20
mm Hg), and, if left untreated, leads
to shock and death. Death will happen
anywhere between 8 and 24 hours after
the first symptoms of circulatory failure
appear.
Hemorrhage may be identified by
Petechiae (small red spots or purple
splotches or blisters under the skin),
bleeding in the nose or gums, dark stools,
or simple bruising. This type of dengue
fever can be fatal, and it can lead to
dengue shock syndrome, the most serious
cause of the disease.
Dengue virus infection causes eye
involvement, but the precise mechanism is
unknown. Viruses, immune mediation,
capillary leakage, stress, and hemorrhage
have all been suspected as possible
triggers. When the platelet count is at its
lowest, and when it starts to increase, eye
involvement is common.
d. Prognosis
According to Smith (2020), dengue fever is typically a self-limited disease.
Paddock (2018) and WebMD (2019) added no specific treatment or cure for the
dengue virus. However, interventions can help, depending on how severe the
disease is.
Early treatment within 48–72 hours of fever onset with an effective antiDENV drug could potentially lower the viral load and reduce dengue severity.
Furthermore, according to the World Health Organization (2009), recovery from the
infection is believed to provide lifelong immunity against that specific serotype.
Nevertheless, cross-immunity to the other serotypes after recovery is only partial
Page 33 of 60
and temporary. Subsequent infections (secondary infection) by different serotypes
increase the risk of developing severe dengue.
Severe dengue fever may have a mortality rate of 10% to 20% if left
untreated. The mortality rate is reduced to about 1% when appropriate supportive
treatment is given (Schaefer, 2020; Smith, 2020). According to the study by
Anuradha and Dandekar (2014), if the illness is not identified early in the course
and not treated when indicated, the case fatality rate of Dengue Hemorrhagic Fever
can go over 20%, and that of Dengue Shock Syndrome (DSS) can be as high as
44%. Also, Junia, Garna, and Setiabudi (2007) stated that Dengue DSS is a severe
complication of dengue hemorrhagic fever (DHF) which may cause death in more
than 50% of cases.
Page 34 of 60
Laboratory & Diagnostic Tests
March 15, 2021 @ 9:45am
Laboratory & Diagnostic
Procedure
Indications & Purposes
Results/
Interpretation
Normal Values
Nursing Responsibilities
Complete Blood Count – to look for low platelet count typical of the later stages of the illness and detect the decrease in hemoglobin, hematocrit,
and red blood cell (RBC) count as evidence of anemia that would occur with blood loss associated with severe dengue fever. Blood testing detects
the dengue virus or antibodies produced in response to dengue infection.
Parameters
Examination
Hemoglobin
Hematocrit
The test is used to screen for, diagnose, or monitor a number of conditions and diseases that affect red
blood cells (RBCs).
The test measures the proportion of
red blood cells in the blood.
146g/L
Within the normal range.
43%
Within the normal range.
•
140 – 180g/L
•
•
0.40 - 0.48%
•
Red Blood Cell
To evaluate number of red blood
cells (RBCs), to screen for, help diagnose, or monitor conditions affecting
red blood cell.
4.68 10^12/L
Within the normal range.
Explain the test procedures.
Explain that slight discomfort maybe felt
when skin is punctured.
Apply manual pressure
and dressing over puncture site.
Explain the interpretation to the patient and
patient’s family.
4.5 – 5.0 10^12/L
Page 35 of 60
MCH
MCV
MCHC
White Blood Cell
MCH is the average amount of hemo21.8pg
globin found in red blood cells in the MCH is low, can be sign for
body.
hypochromic microcytic
anemia, indicates presence
of iron deficiency anemia.
This measures the average volume
of red blood cells.
28 – 33pg
70.7fl
MCV is low, patient indicates microcytic.
82 – 98fl
30.9g/L
MCHC is low and can be
sign for hypochromic microcytic anemia related to
lack of iron.
33 – 36g/L
This determines to screen for or diagnose variety conditions that can
affect the number of white blood
cells (WBCs), such as infection, inflammation or disease that affects
WBCs.
5.2 10^9/L
Within the normal range.
4.8 – 10.8 10^9/L
Provide the doctor with important
clues about the health of the patient.
Having a high percentage of neutrophils in the blood is called neutrophilia, a sign that the body has an infection.
55%
Within the normal range.
MCHC is the average concentration
of hemoglobin per erythrocyte.
Differential Count
Neutrophil
40 – 70%
Page 36 of 60
Lymphocyte
Monocyte
Eosinophil
Basophil
This measures the level of white
blood in the body. High lymphocyte
blood levels indicate the body is dealing with infection or other inflammatory condition.
35%
Within the normal range.
19 – 48%
Help in diagnosing infection. Low
levels indicate the presence of
chronic infections or a bone marrow
issue, while high levels indicate the
presence of chronic infections or autoimmune disease.
7%
Within the normal range.
3 – 9%
9%
Eosinophil count is high,
indicate as Eosinophilia. It
can be a sign of allergic reaction, asthma, parasitic
infection, or chronic myeloid leukemia.
2 – 8%
1%
Basophil is high, indicate
as basophilia. It can be a
sign of chronic inflammation.
0 – 0.5%
A blood test that counts the number
of eosinophils, a form of white blood
cells.
Test to help diagnose certain health
problems such as allergic reaction. It
measures basophils in whole blood
for the evaluation and management
of allergic, hematologic, and neoplastic disorders, as well as parasitic
infections.
Page 37 of 60
Hematocrit
Platelet count
This measures the volume of cells as
a percentage of the total volume of
cells and plasma in whole blood.
To determine the number of platelets
in a sample of your blood.
0.33%
Patient hematocrit count is
low, patient shows positive
for anemia.
0.40 – 0.48%
97 10^9/L
Platelet count is low,
patient indicates for thrombocytopenia.
150 – 400 10^12/L
Page 38 of 60
March 16,2021 @ 3:00 pm
Laboratory & Diagnostic
Procedure
Indications & Purposes
Results/
Interpretation
Normal Values
Nursing Responsibilities
Complete Blood Count – to look for low platelet count typical of the later stages of the illness and detect the decrease in hemoglobin, hematocrit,
and red blood cell (RBC) count as evidence of anemia that would occur with blood loss associated with severe dengue fever. Blood testing detects
the dengue virus or antibodies produced in response to dengue infection.
Parameters
Examination
Hemoglobin
Hematocrit
The test is used to screen for,
diagnose, or monitor a number of
conditions and diseases that affect
red blood cells (RBCs).
152g/L
Within the normal range.
140 – 180g/L
The test measures the proportion of
red blood cells in the blood.
To evaluate number of red blood
cells (RBCs), to screen for, help
diagnose, or monitor conditions
affecting red blood cell.
•
•
45%
Within normal range.
Red Blood Cell
•
0.40 - 0.48%
•
Explain the test procedures.
Explain that slight discomfort maybe felt when
skin is punctured.
Apply manual pressure
and dressing over puncture site.
Explain the interpretation
to the patient and patient’s family.
4.5 – 5.0 10^12/L
Page 39 of 60
MCH
MCV
MCHC
White Blood Cell
Differential Count
Neutrophil
MCH is the average amount of
hemoglobin found in red blood cells
in the body.
28 – 33pg
This measures the average volume
of red blood cells.
82 – 98fl
MCHC is the average concentration
of hemoglobin per erythrocyte.
This determines to screen for or
diagnose variety conditions that can
affect the number of white blood
cells (WBCs), such as infection,
inflammation or disease that affects
WBCs.
Provide the doctor with important
clues about the health of the
patient. Having a high percentage
of neutrophils in the blood is called
neutrophilia, a sign that the body
has an infection.
33 – 36g/L
5.9 10^9/L
Within the normal range.
4.8 – 10.810^9/L
40 – 70%
Page 40 of 60
Lymphocyte
Monocyte
Eosinophil
Basophil
This measures the level of white
blood in the body. High lymphocyte
blood levels indicate the body is
dealing with infection or other
inflammatory condition.
Help in diagnosing infection. Low
levels indicate the presence of
chronic infections or a bone marrow
issue, while high levels indicate the
presence of chronic infections or
autoimmune disease.
A blood test that counts the number
of eosinophils, a form of white
blood cells.
Test to help diagnose certain health
problems such as allergic reaction.
It measures basophils in whole
blood for the evaluation and
management
of
allergic,
hematologic,
and
neoplastic
disorders, as well as parasitic
infections.
19 – 48%
3 – 9%
2 – 8%
0 – 0.5%
Page 41 of 60
Hematocrit
Platelet count
This measures the volume of cells
as a percentage of the total volume
of cells and plasma in whole blood.
To determine the number of
platelets in a sample of your blood.
0.40 – 0.48%
80 10^9/L
Platelet count is low,
patient indicates for
thrombocytopenia.
150 – 400 10^/L
Page 42 of 60
March 17,2021 @ 6am
Laboratory & Diagnostic
Procedure
Indications & Purposes
Results/
Interpretation
Normal Values
Nursing Responsibilities
Complete Blood Count – to look for low platelet count typical of the later stages of the illness and detect the decrease in hemoglobin,
hematocrit, and red blood cell (RBC) count as evidence of anemia that would occur with blood loss associated with severe dengue fever. Blood
testing detects the dengue virus or antibodies produced in response to dengue infection.
Parameters
Examination
Hemoglobin
Hematocrit
Red Blood Cell
MCH
The test is used to screen for,
diagnose, or monitor a number of
conditions and diseases that affect
red blood cells (RBCs).
The test measures the proportion of
red blood cells in the blood.
•
157g/L
Within the normal range.
140 – 180G/L
40%
Within normal range.
0.40 - 0.48%
•
•
•
To evaluate number of red blood
cells (RBCs), to screen for, help
diagnose, or monitor conditions
affecting red blood cell.
4.5 – 5.0 10^12/L
MCH is the average amount of
hemoglobin found in red blood cells
in the body.
28 – 33pg
Explain the test procedures.
Explain that slight discomfort maybe felt when
skin is punctured.
Apply manual pressure
and dressing over puncture site.
Explain the interpretation
to the patient and patient’s family.
Page 43 of 60
MCV
MCHC
White Blood Cell
Differential Count
Neutrophil
Lymphocyte
This measures the average volume
of red blood cells.
82 – 98fl
MCHC is the average concentration
of hemoglobin per erythrocyte.
This determines to screen for or
diagnose variety conditions that can
affect the number of white blood
cells (WBCs), such as infection,
inflammation or disease that affects
WBCs.
Provide the doctor with important
clues about the health of the
patient. Having a high percentage of
neutrophils in the blood is called
neutrophilia, a sign that the body
has an infection.
This measures the level of white
blood in the body. High lymphocyte
blood levels indicate the body is
dealing with infection or other
inflammatory condition.
33 – 36g/L
5.0 10^9/L
Within the normal range.
4.8 – 10.8 10^9/L
40 – 70%
19 – 48%
Page 44 of 60
Monocyte
Eosinophil
Basophil
Hematocrit
Platelet count
Help in diagnosing infection. Low
levels indicate the presence of
chronic infections or a bone marrow
issue, while high levels indicate the
presence of chronic infections or
autoimmune disease.
3 – 9%
A blood test that counts the number
of eosinophils, a form of white blood
cells.
2 – 8%
Test to help diagnose certain health
problems such as allergic reaction.
It measures basophils in whole
blood for the evaluation and
management
of
allergic,
hematologic,
and
neoplastic
disorders, as well as parasitic
infections.
This measures the volume of cells as
a percentage of the total volume of
cells and plasma in whole blood.
To determine the number of
platelets in a sample of your blood.
0 – 0.5%
0.40 – 0.48%
150 10^9/L
Within the normal range.
150 – 400 10^9/L
Page 45 of 60
Medical Management
A. Pharmacotherapy, Intravenous Fluids & Nursing Responsibilities
Drug Study: PNSS
Dr. Macarat ordered: 1L and regulate to 20 gtts/hr
Drug
Mechanism of Action
•
Generic Name:
Plain Normal Saline
Solution
•
Brand Name:
Plain NSS
Classification:
Isotonic Intravenous Fluid
Dose, Route
Timing:
&
Normal saline is sterile,
nonpyrogenic solution
for fluid and electrolyte
replenishment.
Normal saline solution
has an osmolality. Because the osmolality is
entirely contributed by
electrolytes, the solution
remains within the ECF,
does not cause red
blood cells to shrink or
swell. Isotonic fluids expand the ECF volume.
Indications or PurContraindications
Side Effects
pose
• Indicated for re- Contraindicated
for • Hypotenpatients
with:
placement of extrasion
• heart failure
cellular fluid.
• Used since it has lit- • pulmonary
edema
tle to no effect on
•
renal impairment
patient but help in
hydration, prevent- • sodium retention
ing
hypovolemic
shock or hypotension.
Adverse Reactions
Adverse effects include
• febrile response
• infection at IV
site
• venous thrombosis
• extravasation
• hypervolemia.
Nursing Responsibilities
•
•
•
•
Obtain history of the patient’s
fluid and electrolyte status before therapy.
Check the fluid for a safe administration.
Monitor patient frequently for
any signs of infiltration, phlebitis, and condition of the skin
Inform patient to notify the
nurse if any side and adverse
effects had occurred.
IV 1L 20gtts/hr x 2
Drug Study: ORS
Dr. Macarat ordered: 200 cc distilled H2O + 1 sachet ORS
Page 46 of 60
Drug
Mechanism of Action
Generic Name:
Combination of Carbohydrate and electrolytes are
used to treat or prevent dehydration that may occur
with diarrhea. It may not immediately stop diarrhea but
it replaces the water and
electrolytes that are lost
from the body which then
prevent more serious problems.
Oral Rehydration
Salts
Brand Name:
N/A
Classification:
Dose, Route
Timing:
&
PO,
200cc
distilledH2O+ 1 sachet
ORS
Indications or Purpose
For replacement of water and electrolyte that
were lost associated
with diarrhea and vomiting.
Contraindications
Side Effects
Known hypersensitiv- Side effects inity to medicines that clude:
contain
potassium, • mild vomiting
sodium,
citrates,
when thersugar, or rice.
apy has begun.
• symptoms of
hypernatremia
such as dizziness,
fast
heartbeat,
high BP, irritability, restlessness, and
weakness)
may be experienced.
Adverse Reactions
Adverse reactions
include:
• vomiting
• convulsion
• dizziness
• tachycardia
• high blood pressure
• muscle twitching
• swelling of feet
or lower legs
along with puffy
eyelids
• weakness
• puffy eyelids.
Nursing Responsibilities
•
•
•
•
Assess vital signs, noting peripheral pulses.
Strictly monitor the intake
and output.
Encourage to continue ORS
therapy even when mild vomiting occurred; in frequent,
small amounts of solution administered slowly.
Observe the physical properties of the urine as the color
could be an indication
whether the patient is hydrated or still dehydrated.
Page 47 of 60
Drug Study: Paracetamol
Dr. Macarat ordered: 250 mg 1 cap Q4Hr PRN
Drug
Mechanism of Action
Generic Name: Decreases fever by a hypothalamic effect leading
Paracetamol
to sweating and vasodilation, inhibits pyrogen effect on the hypothalamicheat- regulating centers,
inhibits CNS prostaglanBrand Name:
din synthesis with miniBiogesic, Tylenol mal effects on peripheral
prostaglandin synthesis.
Classification:
Analgesic,
Antipyretic
Dose, Route &
Timing:
Dose: 250 mg
Route:Orally
Timing: q4 PRN
Indications or
Purpose
To relieve mild to
moderate pain from
headache,
muscle
ache, backache, minor arthritis, common cold, toothache,
or menstrual cramps;
to reduce fever.
Contraindications
Contraindications to
the use of acetaminophen
include
hypersensitivity
to
acetaminophen, severe hepatic impairment, or severe active hepatic disease.
Side Effects
Side effects include:
• Nausea
• stomach pain
• loss of appetite
• itching
• rash
• headache
• dark urine
• drowsiness
Adverse Reactions
GI: Abdominal pain,
hepatotoxicity, nausea,
vomiting
HEME: Hemolytic anemia, leukopenia, neutropenia, pancytopenia,
thrombocytopenia
SKIN: Acute generalized
exanthematous pustulosis, jaundice, pruritus,
rash, Stevens Johnson
syndrome, toxic epidermal
necrolysis, urticaria
Nursing Responsibilities
•
•
•
•
•
Encourage patient to take it
with food or drink to minimize
GI upset.
Instruct patient to report if
cyanosis, shortness of breath,
and abdominal pain has occurred.
Inform patient to notify prescriber if paleness, weakness,
jaundice, itchiness, and dark
urine are present.
Monitor patient if pain persists for more than 3-5 days.
Monitor patient’s response to
the therapy.
Other: Anaphylaxis, angioedema,
hypersensitivity reaction,
hypoglycemic coma
Page 48 of 60
B. Diet & Activity Management & Nursing Responsibilities
Type of Diet/Activity
Diet as Tolerated
(DAT)
General Description
Usually, orders given regarding dietary restrictions
after a medical procedure.
This means that a person
should be careful of what
they eat.
Indication or Purposes
This diet is given when client
can now tolerate any food,
she desires that is nutritious,
if this will not lead to any
complications and if the client needs further monitoring
for lab test.
Restricted Foods/Activities
Nursing Responsibilities
Foods that is intolerable to ingest • Discuss to the client the
by the patient like highly proimportance of following
cessed foods, trans fat, added
any restrictions of the food
sugar and salts refined grains and
to avoid any complicaalcohol.
tions.
• Explain to the client to
identify foods and drinks
that is difficult to ingest, to
avoid ingesting it.
Page 49 of 60
Summary of Medical Management
A. Pharmacotherapeutics
Date &
Time
Medication
Classification
Dosage
Route
03/15/2021
– 10:00AM
Paracetamol
Antipyretic, analgesic
1 cap
(250mg)
Orally
200cc distilled H2O
+1 sachet
ORS)
Orally
03/15/2021
– 10:00AM
Oral Rehydration
Salts (ORS)
B. Intravenous Fluids
Date &
Time
03/15/2021
– 10:00AM
03/15/2021
– 3:00PM
Bottle
No.
1
2
Type of IV Fluid &
Volume
Plain Normal Saline
Solution
Plain Normal Saline
Solution
Rate
Incorporation
20 gtts/hr.
None
20 gtts/hr.
None
Page 50 of 60
Nursing Care Plan
A. Problem List (Summary)
Cues
Nursing Diagnosis
Definition
Persistent pain in the
epigastric area.
Acute pain related to
pathological
disease
process as evidenced by
persistent epigastric pain
secondary to dengue
fever.
Unpleasant sensory and
emotional
experience
associated with actual or
potential tissue damage, or
described in terms of such
damage; sudden or slow
onset of any intensity from
mild to severe and with a
duration of less than 3
months.
Fever
Hyperthermia related to
increase in metabolic rate
as
evidenced
by
temperature of 38.6
degrees Celsius, flushed
skin, tachycardia and
tachypnea.
Core
body
temperature
above the normal diurnal
range due to failure of
thermoregulation.
Fever and Vomiting
Risk for Bleeding related Susceptible to decrease in
to altered clotting factor blood volume, which may
as evidenced by low compromise health.
platelet count secondary
to dengue fever.
Page 51 of 60
Nursing Care Plan
Patient’s Code: JXDN
03/15/2021 @ 10:00 am
Age: 12-year-old
Room: 8
Sex: Male Civil Status: Single Religion: Roman Catholic Date & Time of Admission:
Attending Physician: Dr. Macarat
Chief Complaints: Persistent pain in the epigastric area
Nursing Diagnosis (PES): Acute pain related to pathological disease process as evidenced by persistent epigastric pain secondary to dengue fever.
Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage; sudden
or slow onset of any intensity from mild to severe and with a duration of less than 3 months
Assessment/ Cues
Planning
Interventions
Rationale
Evaluation
(Subjective/ Objective)
(Goals and Objectives)
Subjective Data
After 8 hours of nursing Independent
After 8 hours of
nursing care, client
•
(+) persistent abdominal care, the client will be • Provide client with calm and quiet • Relaxation techwas able to:
pain in epigastric area that able to:
environment
niques, (e.g., fobegan 2 days PTA
cused breathing, vis• Teach relaxation techniques to the
•
Report
that
pain
is
reualization, guided im- • Adhere to treat•
Pain is 5/10
client and provide diversional activilieved or controlled.
ment regimen as
agery) diversional acties
ordered by physi• Determine ways to re- • Encourage presence of parent
Objective Data
tivities, (e.g., watchcian
lieve pain.
• Weak-looking
ing tv and socializa• Demonstrate use of re• Flushed face
tion with others) and • Make effective use
• (+) epigastric tenderness
of nonpharmacolaxation
techniques
comfort measures
• HR: 120 bpm
and diversional activilogic methods of
(e.g., presence of
• RR: 24 bpm
ties.
pain management
parent) are nonphar• T: 38.6°C
macological methods • Verbalize pain is
relieved or is tolerof pain relief.
able as evidenced
• Monitor skin color, temperature, • These are usually alby stable vital signs
tered when client exand vital signs
periences pain
Page 52 of 60
•
Perform pain assessment every time •
pain occurs
•
Encourage verbalization of feelings •
about pain
Dependent
• Determine and document presence •
of possible pathophysiological and
psychological causes of pain
• Administer pain medication as or- •
dered
Collaborative
• Collaborate in treatment of underlying condition or disease process
causing pain and proactive management of pain
•
To determine improvement or to
identify if client’s
condition is worsening
To evaluate coping
abilities and to identify areas of additional concern
and no longer
weak-looking
Client may have a
condition that contributes to pain felt
Medications may be
prescribed by the
physician to manage
client’s pain
For promotion of effective intervention.
Page 53 of 60
Nursing Care Plan
Patient’s Code: JXDN
03/15/2021 @ 10:00 am
Age: 12-year-old
Room: 8
Sex: Male Civil Status: Single Religion: Roman Catholic Date & Time of Admission:
Attending Physician: Dr. Macarat
Chief Complaints: Fever
Nursing Diagnosis (PES): Hyperthermia related to increase in metabolic rate as evidenced by temperature of 38.6 degrees Celsius, flushed skin, tachycardia
and tachypnea.
Definition: Core body temperature above the normal diurnal range due to failure of thermoregulation.
Assessment/ Cues
Planning
Interventions
(Subjective/ Objective)
(Goals and Objectives)
Subjective Data
After 8 hours of nursing Independent
Pt. complains of fever.
intervention, patient will • Monitor heart rate and rhythm.
•
improve her temperature
Objective Data
as evidenced by the ff:
• BP: 90/60
• HR: 120 bpm
• Patient will maintain a
• RR: 24 bpm
temperature
within
• T: 38.6 C
the normal range.
• Flushed face
• Patient will establish a
normal heart rate and • Record all sources of fluid loss such •
rhythm.
as urine, vomiting and diarrhea.
•
Provide tepid sponge bath.
•
Rationale
Dysrhythmias and
ECG changes are
common due to electrolyte imbalance
and dehydration and
direct effect of hyperthermia on blood
and cardiac tissues.
To monitor or potentiates fluid and electrolyte loses.
To decrease temperature by means
through evaporation
and conduction.
Evaluation
After 4 hrs. of nursing
interventions,
the
patient
was
able
improve
her
temperature
as
evidenced by the ff:
•
•
Patient has maintained a temperature within the normal range.
Patient has established a normal
heart rate and
rhythm.
Page 54 of 60
•
•
Provide a cooling blanket as indicated.
Maintain bed rest.
Dependent
• Provide supplemental oxygen.
• Administer replacement fluids and
electrolytes.
• Provide a high calorie diet or as indicated by the physician.
• Administer antipyretics orally or
rectally as prescribed by the physician.
Collaborative
• Inquire physician with the needed
medications and oxygenation.
•
Inquire nutritionist with the
needed diet.
•
•
To minimize shivering.
To reduce metabolic
demands and oxygen
consumption.
•
To support circulating volume and tissue perfusion.
•
To increase metabolic demands.
To facilitate fast recovery.
•
•
Collaboration with
health professionals
hastens patient recovery.
Page 55 of 60
Nursing Care Plan
Patient’s Code: JXDN
03/15/2021 @ 10:00 am
Age: 12-year-old
Room: 8
Sex: Male Civil Status: Single Religion: Roman Catholic Date & Time of Admission:
Attending Physician: Dr. Macarat
Chief Complaints: Fever and Vomiting
Nursing Diagnosis (PES): Risk for Bleeding related to altered clotting factor as evidenced by low platelet count secondary to dengue fever.
Definition: Susceptible to decrease in blood volume, which may compromise health.
Assessment/ Cues
Planning
Interventions
(Subjective/ Objective)
(Goals and Objectives)
Subjective Data
Short term goal
Independent
Not verbalized by the pt.
After 1 day of nursing • Establish and good working condiintervention:
tion with the mother and client.
Objective Data
• BP: 90/60
1.
The client's mother • Assess for signs and symptoms GI
• HR: 120 bpm
will learn through health
bleeding, nosebleed, and epigastric
• RR: 24 bpm
teaching
and
pain. Note for the color of the stool
• T: 38.6°C
demonstrating the skills
and vomitus.
• Observed weakness
and
practices
in
• Observe for the presence of pete• Platelet count: 97
preventing injury to the
chiae, ecchymosis, bleeding for one
client that will cause him
or more sites.
to bleed and to identify
the signs and symptoms
of
ongoing
internal
bleeding.
• Monitor vital signs especially pulse
2.
The client will be
rate and BP.
able
to
demonstrate
behaviours that reduced
the risk of bleeding as
evidenced by:
Rationale
•
•
•
•
To gain with the
mother and patient’s
cooperation.
The GI tract is the
most usual source of
bleeding due to its
mucosal fragility.
Sub-acute disseminated intravascular
coagulation may develop secondary to
altered clotting factor
An increase in pulse
with a decrease in BP
can indicate loss of
circulating blood volume.
Evaluation
At the end of the
nursing intervention
the goal was met as
evidenced by:
1. The client's mother
learned through health
teaching
and
demonstrating
the
skills and practices in
preventing injury to
the client that will
cause him to bleed
and to identify the
signs and symptoms of
ongoing
internal
bleeding
2.
The
client
demonstrated
behaviors
that
Page 56 of 60
•
Gaining
good • Instruct the client to avoid dark
appetite
colored foods/fluids.
•
Increase in fluid • Instruct the client to eat rich in vitintake
amin C food and encourage to
•
Avoidance of dark
drink a lot of water or fluids.
colored foods/ fluids and
eating food rich in vitamin
Dependent
C.
• Administer RBCs, platelets, clotting
Long term goal
factors.
After 3-4 days of nursing
intervention:
1.
The client will have Collaborative
a normal CBC in Hb, Hct, • Monitor laboratory results in Hb,
Hct, WBC, and platelet count every
WBC, and platelet count
12 hours.
•
Communicate anticipated need for
platelet support to transfusion center.
•
•
•
•
•
reduced the risk of
bleeding by gaining
appetite,
drinking
water/fluids on the
desired intake, eating
fruits and vegetables,
and avoiding darkcolored food/ fluids.
Restores/normalizes
3. the client's CBC in
RBC. Used to prevent Hb, Hct, WBC, and
hemorrhage.
platelet count is within
the normal range.
These are indicators
of anemia, active
bleeding, and impending complications.
To assure availability
and readiness of
platelets when
needed.
Dark colored foods
may mask bleeding.
To boost body resistance and prevent
dehydration.
Page 57 of 60
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