Case Study - Dengue

PAMANTASAN NG LUNGSOD NG PASIGAlcalde Jose St., Kapasigan, Pasig City

COLLEGE OF NURSING

In partial fulfillment in our Related Learning Experience

A Case Study of

DENGUE HEMORRHAGIC FEVER

(DHF)

STUDENT STAFF NURSES

LUNGAN, Aryan Tereza C.MENDOL, Jessica A.

ACEVEDA, Keofome L.STUDENT HEAD NURSE

CLINICAL INSTRUCTORMa’am Josefina R. Maquiling

December 14, 2010 (TUESDAY)PEDIA WARD

I N T R O D U C T I O N

The purpose of the study is to be familiarized with Dengue Hemorrhagic Fever

(DHF); its transmission, disease process, signs and symptoms and most especially on how this can

be treated or prevented.

Dengue hemorrhagic fever (also called H-fever, Breakbone or Dandy fever) is a severe,

potentially deadly infection spread by certain species of mosquitoes (Aedes aegypti). Aedes aegypti,

the transmitter of the disease, is a day-biting mosquito which lays eggs in clear and stagnant water

found in flower vases, cans, rain barrels, old rubber tires, etc. Four serotypes of dengue viruses (1,

2, 3, and 4 Group B Arboviruses) are known to cause dengue hemorrhagic fever. There are three

other arboviruses that have been identified with dengue-like diseases namely Chikungunya,

O’nyong nyong and West Nile fever. Dengue hemorrhagic fever occurs when a person catches a

different type dengue virus after being infected by another one sometime before. Prior immunity to

a different dengue virus type plays an important role in this severe disease.

The Department of Health warned the public about the rising number of dengue cases in the

country, which reached 11,803 cases from January 1 to March 27, 2010. The DOH said the number

of dengue cases is 61% higher than the 7,335 cases recorded during the same period last year. Dr.

Eric Tayag, head of the DOH National Epidemiology Center, said the El Niño phenomenon could

have something to do with the increase in dengue cases. He said the number of dengue cases also

shot up in 1998 when the El Niño phenomenon was felt in the country.

Sources

1. Infected persons – the virus is present in the blood of patients during the acute phase of

the disease and will become a reservoir of virus, accessible to mosquitoes which may

transmit the disease.

2. Standing water within the household and premises are usual breeding places.

Incubation Period

4- 6 days (minimum=3days; maximum=10days)

Period of Communicability

Unknown. Presumed to be on the 1st week of illness—when virus is still present in the blood.

Susceptibility, Resistance and Occurrence

All persons are susceptible. Both sexes are equally affected. Age groups predominantly

affected are the preschool and school age. Adults and infants are not exempted. Peak age affected 5-

9 years. Occurrence is sporadic throughout the year. Epidemic usually occur during the rainy

seasons—June-November. Acquired immunity may be temporary but usually permanent.

Signs and Symptoms

An acute febrile infection of sudden onset with clinical manifestation of 3 stages:

First 4 days—Febrile or invasive stage starts abruptly as high fever, abdominal pain and

headache; later flushing which may be accompanied by vomiting, conjunctival infection and

epistaxis. Petechiae may be observed in pressure areas usually first on the face or distal

portions of the extremities.

4th-7th days—Toxic or hemorrhagic stage—lowering of temperature, severe abdominal

pain, vomiting and frequent bleeding from gastrointestinal tract in the form of hematesis or

melena. Unstable BP, narrow pulse pressure and shock may occur. Tourniquet test which

may be negative due to low or vasomotor collapse.

7th-10th days—convalescent or recovery stage generalized flushing with intervening areas

of blanching appetite regained and blood pressure already stable.

Grading of Dengue Fever

The severity of DHF is categorized into four grades:

• Grade I, fever without overt bleeding but with positive tourniquet test

• Grade II, manifestation of Grade I with clinical bleeding diathesis such as epistaxis, gum bleeding, GI bleeding and hematemesis

• Grade III, circulatory failure manifested by a rapid and weak pulse with narrowing pulse pressure (20 mmHg) or hypotension, with the presence of cold clammy skin and restlessness; and

• Grade IV, profound shock in which pulse and blood pressure are not detectable. It is noteworthy that patients who are in threatened shock or shock stage, also known as dengue shock syndrome, usually remain conscious.

Grade III and IV are considered to be Dengue Shock Syndrome

Laboratory and Diagnostic Tests

1.) Tourniquet Test (Rumpel Leads Tests)

• Inflate the blood pressure cuff on the upper arm to a point midway between the systolic and

diastolic pressure for 5 minutes

• Release cuff and make an imaginary 2.5 cm square or 1 inch just below the cuff, at the antecubital

fossa

• Count the number of petechiae inside the box

• A test is (+) when 20 or more petechiae per2.5 cm square or 1 inch square is observed.

2.) A confirmed diagnosis is established by culture of the virus, polymerase chain reaction (PCR)

tests, or serologic assays.

The diagnosis of dengue hemorrhagic fever is made on the basis of the following triad of

symptoms and signs: Hemorrhagic manifestations; a platelet count of less than 100, 000 per cubic

millimeter (thromobocytopenia); and objective evidence of plasma leakage, shown either by

fluctuation of packed cell volume (greater than 20 percent during the course of the illness) or by

clinical signs of plasma leakage, such as pleural effusion, ascites or hypoproteinemia. Hemorrhagic

manifestations without capillary leakage do not constitute dengue hemorrhagic fever.

Management

Supportive and symptomatic treatment should be provided:

Promote rest

Medication

There are no specific antivial drugs.

Paracetamol – for fever

Analgesic (Acetaminophen (Tylenol) and codeine) – for severe headache and joint and

muscle pains

Aspirin and nonsteroidal antiinflammatory drugs should be avoided

o Rapid replacement of body fluids is the most important treatment

Give ORESOL to replace fluid as in moderate dehydration at 75ml/kg in 46 hours or up to

23L in adults. Continue ORS intake until paient’s condition improves.

Intravenous fluid

o For hemorrhage

Keep patient at rest during bleeding periods

For epistaxis – maintain an elevated position of trunk and promote vasoconstriction in nasal

mucosa membrane through an ice bag over the forehead.

For melena – ice bag over the abdomen. Provide support during the transfusion therapy

o Diet

Low fat, low fiber, nonirritating, noncarbonated

Noodle soup may be given

o Observe signs of deterioration (shock) such as low pulse, cold clammy perspiration,

prostration.

o For shock

Place in dorsal recumbent position to facilitate circulation

Provision of warmth through lightweight covers (overheating causesvasodilatation which

aggravates bleeding)

Prevention

The best way to prevent dengue fever is to take special precautions to avoid contact with

mosquitoes.

Eliminate vector by:

Changing water and scrubbing sides of lower vases once a week

Destroy breeding places of mosquito by cleaning surroundings

Proper disposal of rubber tires, empty bottles and cans

Keep water containers covered because Aedes mosquitoes usually bite during the day, be

sure to use precautions especially during early morning hours before daybreak and in the

late afternoon before dark.

Other precautions include:

When outdoors in an area where dengue fever has been found

Use a mosquito repellant containing DEET, picaridin, or oil of lemon eucalyptus

Dress in protective clothing long sleeved shirts, long pants, socks, and shoes

Keeping unscreened windows and doors closed

O B J E C T I V E S

NURSE-CENTERED OBJECTIVES

General Objective

To be knowledgeable about the nature of Dengue Hemorrhagic Fever, management and treatment to be able to render effective nursing care to the client.

Specific Objectives

Upon the completion of this case study, the student-nurses shall have:

Understood the accurate information about the clients past history and illness in relation to

clients condition

Exhibited the anatomy and physiology of the body system involved in the disease.

Acquired knowledge about the specific medications of the patient as well as its action,

indication, contraindications and adverse reaction.

Utilized all the nursing interventions in abiding to the nursing process.

Expounded on the laboratory and diagnostic procedures done with the patient, their

purposes, and specific nursing responsibilities before, during and after the procedure.

And integrated the appropriate health teachings for proper home management of the health

problem and promotion of self care.

N U R S I N G H E A L T H H I S T O R Y

BIOGRAPHIC DATA:

Client X is a 14 year old female who is currently residing at 17 th St. Luzviminda Kenneth Road, Nagpayong Pinagbuhatan, Pasig City. She was born on September 1, 1996. She was the only child of her parents. She is a Roman Catholic. She is a second year student in Nagpayong High School.

CHIEF COMPLAINT:

“pabalik balik ‘yung lagnat ko”, as verbalized by the client.

HEALTH HISTORY:

A. History of Present Illness

Three days prior to admission, the client had fever, headache and abdominal pain. Before

she had fever, she came from school for their practice. After three days, they went to Bro. Francisco

Perez Clinic in Taytay, Rizal for check-up because of abdominal pain. Her blood test results revealed

decrease number of platelets (80g/L) and WBC (2.5g/L). she was diagnosed there having dengue

fever syndrome and was refer to any hospital with request for Complete Blood Count with Platelet

Count, Urinalysis and ordered to take paracetamol by lunch. Then they went to the emergency

room of Pasig City General Hospital.

On the day of admission, the client was ambulatory, had stable vital signs, had weight of 28.3 kg and with flushed skin.

B. Past History

The client already had mumps and chicken pox during childhood. She had complete

immunizations, as verbalized by her mother. She already had fever, cough and colds. She doesn’t

have any food, drug or environmental allergy. As stated by the client, she doesn’t experience any

accidents in the past and this is the first time she was confined into a hospital.

C. Family History

The client is the only child in the family. Her father is already 43 years old and currently

working as a painter, carpenter, or as a construction worker depending on the available job. While

her mother, age 42, is a plain house wife taking care of household chores. Her mother has

hypertension. Her mother also added that they don’t have a history of Tuberculosis, Diabetes, Heart

Disease and Cancer.

FUNCTIONAL HEALTH PATTERNS

1. Health Perception and Health Management Pattern

The client stated that her general health is good for she seldom get sick. She doesn’t have

regular exercise except or the activities in school and the morning exercise during flag ceremonies

on Monday. No cough and colds was noted 3 weeks PTA. She is not drinking liquor nor smoking

cigarettes ever since. It was her first time to be admitted in the hospital. The client said that she

may have acquired her illness from school since there were reported cases of dengue at their

school few days before she was admitted. The important thing she keeps on her mind while she is

in the hospital is that she needs to follow orders from the doctors and nurses to be well so that she

can go to school. Her mother thinks that we can help them by answering their question whenever

something is not clear to them and also by monitoring her daughter’s vital signs. Whenever

someone is sick in the family, they immediately consult their barangay health center and also seek

what they called “albularyo.” They believe in “tawas and hilot” but health center is where they

always consult first.

2.Nutrition and Metabolic Pattern

BEFORE ADMISSION

The client usually eat any available kind of food (fish, meat, vegetables, fruits) but most especially

viands with soup for three meals per day; around 6:00 in the morning, her breakfast comprises of a cup

of fried rice with a fried fish or egg. During morning snacks, she used to eat sandwich or any viand

available at school. During lunch time, her mother prepares a meal comprises of dishes like “nilagang

baka”. She consumes 1-2 cups of rice on the said meal. She used to eat bread or during merienda time.

During dinner, he usually eats “sinigang na baboy”. She drinks 6-8 glasses of water a day, approximately

2000 ml of water (1 cup= 250ml). She doesn’t drink soda because she’s afraid her father might scold

her. She’s is also not fond of eating junk foods and sweets. She used to take supplements and vitamins.

There’s no change in her appetite and there’s no discomfort during eating or drinking. The client

doesn’t have any dentures. She also said that there is no food that she is allergic to.

DURING CONFINEMENT

The client stated that in the hospital, she doesn’t eat a lot but any food available will do. According

to her his appetite slightly decreased because of her not-so-good condition. She consumes three meals a

day. Her meal usually comprises of food with soup and she drinks 6-8 glasses of water a day,

approximately 2000 ml of water (1 cup= 250 ml). She increases her water intake as ordered by the

doctor and nurse.

3.Elimination Pattern

BEFORE ADMISSION

The client’s bowel elimination pattern is once a day-every afternoon. The color of his stool

is from yellow to brown. She also said that she have no difficulty in defecation. With regards to

her urine elimination pattern, she stated that she urinates about 4x a day. The color of her urine is

yellowish one. She doesn’t have any difficulty in urination and doesn’t have excess perspiration.

DURING CONFINEMENT

The client’s bowel elimination and urine elimination does change a little. She urinates more

than 5x a day. The color of the urine is a yellowish one. He defecates once a day at different times

of times of the day. The color of her stool is not dark and it is formed in shape. He has excess

perspiration and odor problems.

4.Activity and Exercise Pattern

BEFORE ADMISSION

The client said that she has a sufficient energy for completing desired required activities at

school and at home. She has no regular exercise except for the activities at school and the

morning exercise during Monday flag ceremonies During her spare time, she used to watch TV

but only for about an hour because most of her time is allocated for doing her assignments and

projects.

DURING CONFINEMENT

Due to the client’s condition, she has little energy for completing desired required activities.

She can’t do all things that she usually do when she was admitted in the hospital.

1st DAY INTERVIEW ( November 15, 2010)

She has perceived ability for:Feeding – 0 and sometimes 2Grooming – 0General Mobility – 0Toileting - 0Cooking – N/AHome maintenance – N/ADressing – 2 because of her IV infusionShopping – N/A

NOTE:Level 0: Full Self CareLevel 1: Requires use of equipment or deviceLevel 2: Requires assistance or supervisions from

another personLevel 3: Requires assistance or supervision from

another person/or deviceLevel 4: Is dependent and does not participate

N/A: Not Applicable

5. Sleep Rest Pattern

BEFORE ADMISSION

The client stated that she has a continuous sleep, which comprises of 5-7 hrs of sleep. She’s

not taking any nap during afternoon because of school assignments. She usually sleeps on a side

lying position. She’s not taking any sleeping pills. She also added that she don’t feel any tiredness

upon waking up.

DURING CONFINEMENT

Now that the client is in the hospital, her sleep is always interrupted due to frequent

monitoring of Vital Signs. Her sleep is also interrupted due to the environment in the hospital. But

sometimes she sleeps for about 4-8 hours. She sleeps in a supine position. Client perceives that the

quality of sleep was the most important rather than the quantity of sleep.

6. Cognitive Perceptual Pattern

The client verbalized that she’s have no hearing difficulty in both ears and so she is not

using hearing aids. She also stated that she doesn’t wear any eyeglasses ever since. She doesn’t have

any history of check- up in any ophthalmologist. His pupils are equally rounded and reactive to light

and accommodation. The client verbalized that she doesn’t have difficulty in reading small writings.

There are no changes in her memory lately, upon assessment it was found out that the client is

oriented to time and place. The easiest way for the client to learn things are through reading. He

doesn’t have any difficulty in learning new things.

7. Self Perception and Self Concept Pattern

The client describes herself as a simple girl living a simple life. She’s a happy person and not

irritable. Before the illness started, there is no hindrance for her to do any activity except that she’s

really not into sports coz of her slim body. She doesn’t mind those few people who make her angry.

She used to just ignore them and just continue with her own life. The thing that makes her cry is

when she can’t go to school or can’t pay school fees because she’s afraid that her teacher might

scold her. She easily cries when she can’t do her projects related to financial matters. Despite of her

condition now she still has positive attitudes about herself.

8. Role-Relationship Pattern

The client belongs to a nuclear family. She is living with her mother and father. She doesn’t

have problems that are difficult to handle. Her family does depends on her father especially on

financial aspects. Everytime she has problems, she immediately consult her mother because most of

the time, her father is at work. Every time their family encounters a problem, they talk about it at

once for them not to prolong their problem. The most common problem that they encounter is

financial. Her support system in time of stress is her friends and family especially her mother.

Whenever her father can support their financial needs just like during her hospitalization, they seek

help from their other relatives. She doesn’t feel alone frequently; in fact she is a cheerful person.

9. Sexually-Reproductive Pattern

The client is already in the latency stage based on Freud’s Psychosexual stages of

development wherein in sexual urges sublimated in to sports and hobbies. She is fond of drawing

but not into sports. She is not active in sexual intercourse. She already had her first menstruation

when she was 13 years old. According to Erickson’s Psychosexual stages of development, he client

is in the stage of identity versus role confusion wherein it’s the time for her to develop an identity,

and decide for her career goals. According to her mother, she is really fond of drawing and very

eager to study and finishes her tasks ahead of time.

10. Coping Stress Tolerance Pattern

The term coping refers to the strategies a person utilize to adapt to physiological and

psychological problem or change. Upon assessment, she feels comfortable and not stress. Things

that stress her are more of the school projects that cause her to sleep late at night sometimes. The

client explained that whenever something bothers her, she easily talks to her mother about it and

so in that way, stress is avoided since her mother is always there to help her.

11. Value-Belief Pattern

The client’s mother verbalized that her daughter is very religious. The client goes to church

every Sunday. And if her mother can’t come with her to church, she goes with her Aunt and doesn’t

want to skip mass on Sundays. She says a prayer every night before she goes to sleep. She knows

that he can’t have everything that she wanted and accepted that but when it comes to school fees,

she really wanted to afford those to avoid being scold. The most important thing in his life now is

her family, health and studies. On a scale of 1-10; 10 being the highest she chose 10. That’s how

much important her family is. She stated that her religious beliefs and practices don’t interfere with

her hospitalization. But being hospitalized interfere with her religious practices since she can’t go

to mass when Sunday.

P H Y S I C A L E X A M I N A T I O N

PARTS METHOD USED FINDINGS INTERPRETATIONG

EN

ER

AL

LOCAppearance

DevelopmentNutritional statusEmotional state

Gait

INSPECTION

Alert, coherence, orientedNo signs of distress

EctomorphCachexic

CalmCoordinated

NORMAL

SK

IN

ColorTextureTurgor

TemperatureMoistureOthers

INSPECTION

FlushedSmooth

FairWarm

Moist, slightly oilyNo lesions, some

petechial rash on legs.

NORMAL

HEA

D

ConfigurationHair

ScalpFace

INSPECTION

NormocephalicEvenly distributed

Presence of dandruffSymmetry

NORMAL

EY

ES

LidsConjunctiva

ScleraCornea & Lens

Pupil SizeVisual acuity

INSPECTION

Symmetrical Pinkish, no discharge

Anicteric Smooth, clear

EqualNormal, do not wear eye

glasses.

NORMAL

EA

RS

External Pinnae

External CanalGross Hearing

INSPECTION

Symmetrical, no tenderness

No dischargesymmetrical

NORMAL

NO

SE &

S

INU

SES Mucosa

PatencyGross smell

Sinuses

INSPECTION &

PALPATION

Pinkish, no dischargeBoth are patent

Symmetricalnontender

NORMAL

EY

ES

LipsTongueTeethGums

MucosaSpeechUvulaTonsils

INSPECTION &

PALPATION

Slightly dryPinkish, midline

Caries, 3 missing teethPinkish, non tenderness

PinkishIntact

Deviation to the RNon inflamed

NORMAL

NEC

K TracheaLymph nodes

Thyroids

INSPECTION &

PALPATION

MidlineNonpalpableNonpalpable

NORMAL

BR

EA

ST

PATIENT REFUSED

TH

OR

AX

&

LU

NG

S Breathing patternShape of chest

PercussionBreath sounds

AUSCULTATION INSPECTIONPALPATION

PERCUSSION

EupneaAP ratio 1:2Resonant Vesicular

NORMAL

AB

DO

MEN Skin

UmbilicusConfigurationBowel sounds

Percussion

INSPECTION AUSCULTATION

PERCUSSION PALPATION

Same with the skin colorSunken

FlatSlightly hyperactive

Tympanic

NORMAL

GEN

ITA

L

&

PATIENT REFUSED

UP

PER

/ L

OW

ER

EX

TR

EM

ITIE

S

SizeSkin colorLesions

TemperatureOthers:

INSPECTION AND PALPATION

Equal sizeLight to deep

No lesionsWarm

Symmetry with visible veins; fingers, arm,

shoulder and wrist can move freely in different direction; mark of some

petechial rash

NORMAL

T H E O R E T R I C A L F R A M E W O R K

The group used the following 4 nursing theories to achieve their aim – health-promoting behavior of the patient: (1) Lydia Hall’s Core, Care and Cure Model, (2) Hildegard Peplau’s Interpersonal Relationship Theory, (3) Florence Nightingale’s Environmental Theory and (4) Imogene King’s Goal Attainment Theory.

The theories of Lydia Hall, Hildegard Peplau, Florence Nightingale and Imogene King

are combined to each other because of their intense interrelationship. Hildegard Peplau’s

Interpersonal Relationship Theory is the backbone of Figure 1, for it illustrates the

interpersonal communication between the patient and healthcare team which affects the

healthcare decision-making and delivery. We may say that Lydia Hall’s Core, Care and Cure

Model & Imogene King’s Goal Attainment Theory and Florence Nightingale’s Environmental

Theory, Imogene King’s Goal Attainment Theory and Care part of Core, Care and Cure

Model happen simultaneously. Environmental Theory is centered at the Care part of Lydia

Hall’s Core, Care and Cure Model. But, it is affected by Imogene King and Hildegard Peplau.

Nightingale states 5 components of environment that the nurse should modify to satisfy the

Care part of Hall’s theory. Modification of the environment should be facilitated by the

nurse because this is an independent nursing intervention. While, Core, Care and Cure

Model and Goal Attainment Theory illustrate the implementation of different specific

needed interventions by the patient, nurse and doctors or other health care team members

through their continuous reaction and interaction. The Transaction phase of Goal

Attainment Theory signifies the evaluation of nursing process. It shows if the goal is met or

not which is health-promoting behavior. Therefore, ongoing assessment will be very

essential to adjust interventions when necessary.

A N A T O M Y & P H Y S I O L O G Y

THE SYSTEMIC CIRCULATION

Major ARTERIES (in bright red) and VEINS (dark red) of the system

Blood from the aorta passes into a branching system of arteries that lead to all parts of the body. It then flows into a system of capillaries where its exchange functions take place.

Function only: to supply materials to — and remove materials from — the capillaries. Blood from the capillaries flows into venules which are drained by veins.

o Veins draining the upper portion of the body lead to the superior vena cava.o Veins draining the lower part of the body lead to the inferior vena cava.o Both empty into the right atrium.

BLOOD

Blood is a liquid tissue. Suspended in the watery plasma are seven types of cells and cell fragments.

red blood cells (RBCs) or erythrocytes platelets or thrombocytes kinds of white blood cells (WBCs) or leukocytes Three kinds of granulocytes Neutrophils eosinophils basophils

Two kinds of leukocytes without granules in their cytoplasm lymphocytes monocytes

FUNCTIONS OF THE BLOOD

Blood performs two major functions: transport through the body of oxygen and carbon dioxide food molecules (glucose, lipids, amino acids) ions (e.g., Na+, Ca2+, HCO3−) wastes (e.g., urea) hormones heat Defense of the body against infections and other foreign materials. All the WBCs participate

in these defenses

TYPES OF BLOOD CELLS

Are produced in the bone marrow (some 1011 of them each day in an adult human!). Arise from a single type of cell called a multipotent stem cell.

STEM CELLS

are very rare (only about one in 10,000 bone marrow cells); are attached (probably by adherens junctions) to osteoblasts lining the inner surface of bone

cavities; produce, by mitosis, two kinds of progeny: More stem cells (A mouse that has had all its blood stem cells killed by a lethal dose of

radiation can be saved by the injection of a singleliving stem cell!). Cells that begin to differentiate along the paths leading to the various kinds of blood cells.

P A T H O P H Y S I O L O G Y

Macrophages & monocytes

Immunoglobulins (Specific antibodies of previous virus strain)

Attachment to the dengue virus to facilitate phagocytosis

Phagocytize the dengue virus

through the Fc receptor (FcR)

Unable to deactivate the virus

Precipitating Factors:

Previous dengue infection Environmental condition Mosquito carrying a different strain

Predisposing Factors:

Age – 32y/o Geographical area

Inflammatory Response

Aedes aegypti (dengue virus carrier): 8-12 days of viral replication on mosquitos’ salivary glands

Bite from mosquito (Portal of Entry in the Skin)

Inoculation of dengue virus in the circulation/blood (Incubation Period: 3-14 days)

Rapid dissemination of dengue virus in the blood

Redness; itchiness in the

area

Virus Replication takes place –

Multiplies & Release to the blood stream

Systemic Infection

Dengue Fever

Decreased WBC

Fever, body weakness,

diaphoresis, headache, warm skin.

N U R S I N G C A R E P L A N

D R U G S T U D Y

PARACETAMOL (Biogesic) 325mg/Tab for FEVER (temp. ≥37.8 0C)

Brand Name Acetaminophen,

Classification ANALGESIC

ActionDecreases fever by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by hypothalamic action leading to sweating & vasodilations.

Indications Relief of mild-moderate pain; treatment of fever.

Contraindications Hypersensitivity, intolerance to tartrazine, alcohol, table sugar and saccharin.

Adverse Effects

CNS: HeadacheCV: Chest pain, dyspnea, myocardial damage when doses of 5–8 g/day are ingested daily for several weeks or when doses of 4 g/day are ingested for 1 yrGI: Hepatic toxicity and failure, jaundiceGU: Acute kidney failure, renal tubular necrosisHematologic: Methemoglobinemia—cyanosis; hemolytic anemia—hematuria, anuria; neutropenia, leukopenia, pancytopenia, thrombocytopenia, hypoglycemiaHypersensitivity: Rash, fever

Drug InteractionToxicity may be increased in patients receiving other potentially hepatoxic drugs that induce liver microsomal enzymes. The absorption on paracetamol may be accelerated by drugs such as metoclopramide.

Nursing Considerations

Do not exceed the recommended dosage. Consult physician if needed for children < 3 yr; if needed for longer than 10 days; if

continued fever, severe or recurrent pain occurs (possible serious illness). Avoid using multiple preparations containing acetaminophen. Carefully check all OTC

products. Give drug with food if GI upset occurs. Discontinue drug if hypersensitivity reactions occur. Treatment of overdose: Monitor serum levels regularly, -acetylcysteine should be available as a specific antidote; basic life support measures

may be necessary.Teaching Point: Do not take for longer than 10 days. Take the drug only for complaints indicated; it is not an anti-inflammatory agent. Avoid the use of other over-the-counter preparations. They may contain

acetaminophen, and serious overdosage can occur. If you need an over-the-counter preparation, consult your health care provider.

Report rash, unusual bleeding or bruising, yellowing of skin or eyes, changes in voiding patterns.

RANITIDINE 30mg IV every 8 hours

Name Zantac, Ramadine

Classification Gastrointestinal Drugs

ActionInhibits histamine at H2 receptor site in the gastric parietal cells, which inhibits gastric acid secretions.

Indications Use in management of various GI disorders such as dyspepsia, GERD, peptic ulcer.

Contraindications Hypersensitivity. History of acute porphyria. Long-term therapy.

Adverse Effects

CNS: Headache, malaise, dizziness, somnolence, insomnia, vertigoCV: Tachycardia, bradycardia, PVCs (rapid IV administration)Dermatologic: Rash, alopeciaGI: Constipation, diarrhea, nausea, vomiting, abdominal pain, hepatitis, increasedALT levelsGU: Gynecomastia, impotence or decreased libidoHematologic: Leukopenia, granulocytopenia, thrombocytopenia, pancytopeniaLocal: Pain at IM site, local burning or itching at IV siteOther: Arthralgias

Drug InteractionIt can increased effects of warfarin, TCAs, Decreased effectiveness of diazepam, Decreased clearance and possible increased, toxicity of lidocaine, nifedipine


Observed the 10 RIGHT’s in drug administration.Assess potential for interaction of other pharmacological agents patient may be taking.Assess the knowledge/teach patient about the possible side effects, appropriate

intervention and adverse symptoms to report.Monitor AST, ALT, serum creatinine when used to prevent stress-related GI bleeding.Inform the patient that it will take several days before noticeable relief.Allow 1 hr between any other antacids & ranitidine.Follow diet as recommended.If you miss a dose, use it as soon as you remember. If it is near the time of the next

dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.

TERBUTALINE 2.5mg/tab 2x a day

Name Bricanyl , Brethine

Classification Respiratory drugs

ActionSpecific beta 2 adrenergic receptor stimulant, resulting to bronchodilation and relaxation of peripheral vasculature. It also causes relaxation of uterine smooth muscles and has minimal beta 1 activity.

IndicationsTerbutaline is given as the sulfate for its bronchodilating properties in reversible airways obstruction. It also decreases uterine contractility and may be used to arrest premature labour.

ContraindicationsHypersensitivity to sympathomimetic agents. Thyrotoxicosis; pregnancy 1st trimester. Cardiac arrhythmias associated with tachycardia.

Adverse EffectsPalpitation, tachycardia, chest discomfort, arrhythmias, hypertension, CNS stimulation, tremor, dizziness, headache, weakness, nausea, vomiting, GI distress, hypokalemia(high doses), dyspnea, sweating, muscle cramps, ECG changes, increased heart rate, seizures.

Drug InteractionBeta-blockers, monoamine oxidase inhibitors, tricyclic antidepressants.Combining terbutaline with thioridazine (Mellaril) may increase the occurrence of abnormal heart rhythms because both drugs can cause abnormal heart rhythms.


Assess patient’s condition before the therapy and regularly monitor drug effectiveness.

Assess respiration (rate, rhythm and character). Monitor and report evidence of allergic reactions, rash, pruritus and urticaria. Monitor for possible drug induced adverse reactions: CNS: nervousness, headache,

drowsiness, dizziness, weakness CV: palpitations, tachycardia, arrhythmia, flushing GI: vomiting, nausea, heartburn METABOLIC: hypokalemia, RESPI: paradoxical bronchospasm, dyspnea SKIN: diaphoresis.

Assess patient’s knowledge on drug therapy. Tech patient to monitor for and report adverse reaction.

L-CARNITINE 330mg/tab 2x a day

Brand Name Carnitor

Classification Amino acid supplement

Action It is needed to release energy from fat. It transports fatty acids into mitochondria, the powerhouses of cells.

Indications

For the acute and chronic treatment of patients with an inborn error of metabolism which results in secondary carnitine deficiency.

For the prevention and treatment of carnitine deficiency in patients with end stage renal disease who are undergoing dialysis.

Used therapeutically to stimulate gastric and pancreatic secretions and in the treatment of hyperlipoproteinemias.

ContraindicationsNone known. The safety and efficacy of oral levocarnitine has not been evaluated in patients with renal insufficiency, pregnant and nursing mothers.

Adverse Effects

Side effects includes abdominal pain, back pain, headache, hypertension, tachycardia, anorexia, diarrhea, dyspepsia, nausea, vomiting, dizziness, weight decrease, paresthesia, pharyngitis, dyspnea, rhinitis.

L-carnitine has not been consistently linked with any toxicity.

Drug Interaction The body needs lysine, methionine, vitamin C, iron, niacin, and vitamin B6 to produce carnitine.Phenobarbitals resulted in reduced blood levels of L-carnitine.


IVF SOLUTIONS

TYPE OF SOLUTION DATE /TIME INDICATION

D5LR 510cc x 6 hours 11-30-10 to 12-03-10 Resembles blood serum and rehydration

http://www.rxlist.com/script/main/art.asp?articlekey=5298

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PNSS 1L x KVO 12-02-10Replace ECF, water overload, medication diluents

& compatible with blood.

D5NM 550cc x 8 hours 12-03-10

Provides water and electrolytes for maintenance of daily fluid and

electrolyte requirements, plus minimal carbohydrate calories.

L A B O R A T O R Y S T U D Y

HEMATOLOGY Date : 11/30/10 TEST INDICATION NORMAL VALUE RESULT INTERPRETATION

Neutrocyte

To identify acute and chronic

illness, bleeding tendencies, and white blood cell

disorders

0.35-0.65% 0.43% Normal

Lymphocyte 0.20-0.40% 0.37% Normal

WBC4.50-11.00 x 10

g/L2.5/l Low

Hemoglobin 115-160g/L 158g/l Normal

Hematocrit 0.40-0.50g/L 0.47g/l Normal

Platelet count 150-400 x 10g/L 80g/lDecreased; possible immune

disorder

HEMATOLOGY Date : 11/30/10 TEST INDICATION NORMAL VALUE RESULT INTERPRETATION

HemoglobinTo identify acute

and chronic illness, bleeding tendencies, and white blood cell

disorders

115-160g/L 165/lIncreased possible for

Polycythemia, dehydration

Hematocrit 0.40-0.50g/L 0.46/l Normal

Platelet count 150-400 x 10g/L 337/l Normal

HEMATOLOGY Date : 12/01/10 (11:54am)

TEST INDICATION NORMAL VALUE RESULT INTERPRETATION

WBCTo identify acute

and chronic illness, bleeding tendencies, and white blood cell

disorders

4.50-11.00 x 10 g/L

5.7g/l Normal

Hemoglobin 115-160g/L 169g/lIncreased possible for

Polycythemia, dehydration

Hematocrit 0.40-0.50g/L 0.53/lIncreased possible for

polycythemia, hemoconcentration.

Platelet count 150-400 x 10g/L 30g/lDecreased; possible immune

disorder

HEMATOLOGY Date : 12/01/10 ( 9:53 pm)


Platelet count



disorders

150-400 x 10g/L 40g/lDecreased; possible immune

disorder

HEMATOLOGY Date : 12/02/10 (1:44 pm)


Platelet count



disorders


disorder

HEMATOLOGY Date : 12/03/10 (3:06 pm)


Platelet count



disorders


disorder

HEMATOLOGY Date : 12/04/10 (11:18am)


Platelet count



disorders


disorder

BLOOD CHEMISTRY (Cardiac Enzymes & Proteins) Date : 12/04/10 (10:01am)


CK-MB Specific indicationfor the diagnosis

of myocardial infarction.

313. – 618. 995. High (possible MI)

LDH 0. – 16. 24.High

(Possible for Acute MI)

BLOOD CHEMISTRY (Cardiac Enzymes & Proteins) Date : 12/04/10 (10:01am)


CK-MB Specific indicationfor the diagnosis

of myocardial infarction.

313. – 618. 1107. High (possible MI)

LDH 0. – 16. 17. Slightly Elevated

D I S C H A R G E P L A N

M- Medication

Continue taking prescribe medication for the patient on exact dosage, time, and frequency

making sure that the purpose of the medication is truly discussed by the health care

provider.

• Instruct the patient to follow the instruction when administering meds.

• Advice the patient not to stop intake of prescribed meds, unless approved by the physician.

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

decrease platelet count should be avoided.

E- 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 health. Remind about the

need for health promotion activities such as reading, watching T.V, etc

T – Treatment

Bed rest is advisable during the re-occurrence of fever phase.

• Instruct to drink plenty of water or fluids that are available at home and eat nutritious diet.

• Advised to look for re-occurrence of danger signs and symptoms and report immediately.

H – Hygiene

Encourage to continue the routinely hygienic care of the patient

O – OPD

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.

D – Diet

Instruct the family members to give the client protein rich foods such as meat, fish, eggs and

dairy products.

Documents

Case Study - Dengue