Liceo de Cagayan University R.N. Pelaez Blvd.

Carmen, Cagayan de Oro City College of Nursing

Submitted to: Mrs. Franelee Zulueta , RN, MN Submitted by: GROUP 15 Ortega, Ailyn Joy Pacapac, Kathleen Love Padeo, Mercy Pamabusao, Irish Bette Pegalan Jenny Penados, Aiko Louigie Ramos, Randy Roque, Mhay Ricamare Rosales, Kristine Ellen Sazon, Gian Carlo Seria, Roy Jr. Tan, Jessamine Grace Tan, Marielle Mae Villamor, Winberly Fatima Zornosa, Maria Socorro

December 10, 2009

I. INTRODUCTION A. OVERVIEW OF THE STUDY

Dengue fever is an infectious disease carried by mosquitoes and caused by any one of the of four dengue viruses. You can get it if an infected mosquito bites you. This disease used to be called "break-bone" fever because it sometimes causes severe joint and muscle pain that feels like bones are breaking, hence the name. Health experts have known about dengue fever for more than 200 years. It occurs in tropical and sub-tropical areas of the world. Symptoms appear 314 days after the infective bite. Dengue fever is a febrile illness that affects infants, young children and adults. Symptoms include a high fever, headaches, joint and muscle pain, vomiting and a rash. Most people with dengue recover within 2 weeks. Until then, drinking lots of fluids, resting and taking non-aspirin fever-reducing medicines might help. It is important to maintain hydration. Sometimes dengue turns into dengue hemorrhagic fever, which causes bleeding from your nose, gums or under your skin. It can also become dengue shock syndrome, which causes massive bleeding and shock. These forms of dengue are life-threatening. Dengue viruses are transmitted to humans through the bites of infective female Aedes mosquitoes. Mosquitoes generally acquire the virus while feeding on the blood of an infected person. After virus incubation for eight to 10 days, an infected mosquito is capable, during probing and blood feeding, of transmitting the virus for the rest of its life. Infected female mosquitoes may also transmit the virus to their offspring by transovarial (via the eggs) transmission, but the role of this in sustaining transmission of the virus to humans has not yet been defined. Infected humans are the main carriers and multipliers of the virus, serving as a source of the virus for uninfected mosquitoes. The virus circulates in the blood of infected humans for two to seven days, at approximately the same time that they have a fever; Aedes mosquitoes may acquire the virus when they feed on an individual during this period.

The mosquito flourishes during rainy seasons but can breed in water-filled flower pots, plastic bags, and cans year-round. One mosquito bite can inflict the disease.The virus is not contagious and cannot be spread directly from person to person. There must be a person-tomosquito-to-another-person pathway Worldwide, 50 to 100 million cases of dengue infection occur each year. This includes 100 to 200 cases in the United States, mostly in people who have recently traveled abroad. During the last part of the 20th century, many tropical regions of the world saw an increase in dengue cases. Epidemics also occurred more frequently and with more severity. In addition to typical dengue, dengue hemorrhagic fever (DHF) and dengue shock syndrome also have increased in many parts of the world. Globally, there are an estimated several hundred thousand cases of DHF per year. According to the World Health Organization, there are an estimated 50 million cases of dengue fever with 500,000 cases of dengue hemorrhagic fever requiring hospitalization each year. Nearly 40% of the world's population lives in an area endemic with dengue.

B. OBJECTIVE OF THE STUDY The study was conducted to determine and identify health problems of the patient to implement nursing interventions that would alleviate her present condition. And thus, be able to impart health teachings in promoting health and prevention of illness; be able to relate applicable recommendations which include referrals and follow-up to intervene on the problems that are being identified and be able to encourage participation on the promotion of health and wellness.

C. SCOPE AND LIMITATIONS This study will act as a baseline data as well as guide for coming up with a good, reliable, accurate and comprehensive research paper dealing with issues commonly experienced by patients in the hospital setting. The study focused on one patient admitted at SABAL HOSPITAL. The time frame of this study begins from the physical assessment last

November 18, 2009 and on the first day of duty last November 19, 2009 up to the 2nd day of exposure November 20, 2009 11-7 shift at Semi-Private Ward, room 401, Station 2. Subjective data gathered were taken from the patient alone. The activities include collecting, organizing, validating and recording any data from the chart, significant others and from our observation, which will be enough to support our study. We had also identified actual problems manifested by the patient and implemented nursing intervention. Furthermore, we had also imparted health teachings that will be beneficial in the promotion of patients health. This study does not involve providing financial assistance or giving false reassurance to the patient as well as their significant others.

II. A. PATIENTS PROFILE Name: D.L Home Address: Kauswagan, CDO Sex: Female Age: 15 years old Religion: Roman Catholic Civil status: Single Education level: 4th year high school Nationality: Filipino Date admitted: November 18, 2009 Time: 12:21 am Attending physician: Dr. Sabal Chief complaint: Fever, Abdominal pain and headache Admitting diagnosis: Dengue fever BP: 110/90 mmHg Pulse rate: 89 bpm Respiratory rate: 26 cpm Temperature: 38.7 c Height: 53 Weight: 58.9 kg B. HISTORY OF PRESENT ILLNESS Patient D.L 15 years old, a 4th year high school student, who has a history of asthma and allergic to pollen grains and dust was admitted on Sabal Hospital last November 18, 2009 at 12:21 am with a chief complaint of abdominal and headache. Prior to admission patient had a fever after being exposed to the rain. She took Biogesic to relieve her fever but it remained unrelieved so she was brought to the hospital. Upon admission patient complained of abdominal pain and headache.

III. DEVELOPMENTAL DATA 1. ROBERT HAVIGHURST: DEVELOPMENTAL TASK THEORY In this theory, the patient belongs to the Adolescence. During this age the patient undergoes the following changes: A. Achieving new and more mature relations with age- mates of both sexes. B. Achieving a feminine/ masculine role. C. Accepting ones physique and using the body effectively. D. Achieving emotional independence from parents and other adults. This explains why the patient seems to give much importance in beautifying self because this is the time where a person is conscious of the biological changes that take place in adolescence. We can relate these developmental tasks to patient D. L because shes 15 years old and at the time of our care to her, she makes it a point that shes neat and clean every time we visit her. She was a bit shy especially when it comes to performing procedures related to her plan of care.
2. ERIK ERIKSON: EIGHT STAGES OF DEVELOPMENT

In this theory, patient belongs to the Adolescence stage which can be classified from 12- 20 years old. The Central Task in this stage is Identity versus role confusion. The indicators of positive resolution are coherent sense of self and plan to actualize ones abilities. The indicators of Negative resolution are feelings of confusion, indecisiveness, and possible antisocial behavior. To evaluate our patient using this theory, she may fall under the ones who manifests positive indicators resolutions. Although our patient may not be that consistent and active when it comes to conversation, you can very well see that she is

trying to slowly share, that she has plenty of friends in school and that they have similar likes and dislikes that enabled them to create a bond. Patient D. L was like a typical teenager that gave importance to her social life and studies. We observed that she was concerned about her studies because even though she was admitted at the hospital, she was worried about her absences that could possibly pull down her grades. Erikson does not believe that the proper solution to a stage crisis is always completely positive. Some exposure or commitment to the negative end of the persons bipolar conflict is sometimes inevitable- you cannot trust all people under all circumstances and survive, for example. Nonetheless, in the healthy solution to a stage crisis, the positive resolution dominates 3. SIGMUND FREUD: PSYCHOSEXUAL THEORY OF DEVELOPMENT Genital stage is the last stage in this theory, this occurs from puberty the after. Energy is directed towards full sexual maturity and function and development of skills needed to cope with the environment. This stage implies Encourage separation from parents, achievement of independence, and decision making. 4. PIAGETS COGNITIVE DEVELOPMENT Cognitive Development refers to the manner in which people learn to think, reason, and use language. It involves a persons intelligence, perceptual ability, ability to process information. Cognitive development represents a progression of mental abilities from illogical to logical thinking, from simple to complex problem solving, and from understanding concrete ideas to understanding abstract concepts. According to Piaget (1966), Cognitive development is an orderly. Sequential process in which a variety of new experiences must exist before intellectual abilities can develop. Piagets phase of cognitive development ends with formal operation phase.

In Patient D. Ls age which belongs to the formal operations phase, there is use of rational thinking and reasoning is deductive and futuristic. This theory can be used in developing teaching strategies like in the case of patient D.L, she is 15 years old and can be expected to use rational thinking and to reason; therefore when explaining the need for a medication, we can outlined the consequences of taking and not taking the medications that enabled our patient to make a rational decision.

IV. DIAGNOSTIC EXAM Diagnostic Exam Nov. 17, 09 CBC Hgb WBC Monocytes Nov. 18, 09 CBC Hgb 0.36 0.37- 0.47 - Anemia, dec. 02 capacity of the blood - Dengue fever - Increased with viral infection - Normal - Normal - Normal - Presence of bacterial infection - Normal - Normal 0.36 0.37- 0.47 - Anemia, dec. 02 capacity of the blood - Infection- Fever - Increased with viral infection Result Normal Values Significance of the Result

2.11 0.41

3.8- 10.8 00- 0.10

Platelet Monocytes Urinalysis Microscopic Sp Gravity Sugar Pus cell Epithelial Albumin 12:05 AM Hematology Platelet count

140 0.14 Yellow 1.015 (-) 3.5 None (-)

150- 400 00- 0.10 Yellow 1.010-1.025 (-) 0-2 None (-)

100,000/mm3

150,000350,000/mm3

- Decreasing platelet count signifies possible

bleeding Platelet count 62,000/mm3 150,000350,000/mm3 - Decreasing platelet count signifies possible bleeding - Decreasing platelet count signifies possible bleeding - Decreasing platelet count signifies possible bleeding

Hematology Platelet count Nov. 19,09 12:05am Hematology Platelet count

68,000/mm3

150,000350,000/mm3

100,00/mm3

150,000350,000/mm3

Nov. 20,09 6:11am Hematology Platelet count

114,000/mm3

150,000350,000/mm3

- Decreasing platelet count signifies possible bleeding - Decreasing platelet count signifies possible bleeding

Platelet count

68,0000/mm3

150,000350,000/mm3

Date Ordered Nov. 19, 09 12:05 Am

I.V Fluids #5 D5LR 1 L @ 40 gtts/min

Clinical significance To replenish fluid and electrolyte in the body and for administration of IVTT meds To replenish fluid and electrolyte in the body and for administration of IVTT meds To replenish fluid and electrolyte in the body and for administration of IVTT meds To replenish fluid and electrolyte in the body and for administration of IVTT meds To replenish fluid and electrolyte in the body and for administration of IVTT meds To replenish fluid and electrolyte in the body and for administration of IVTT meds To replenish fluid and electrolyte in the body and for administration of IVTT meds

Nov. 19,09

#6 D5LR 1 L @ 40 gtts/min

Nov. 19,09 3:00 pm

#7 D5LR 1 L @ 40 gtts/min

Nov. 20,09 3:30 am

#8 D5LR 1 L @ 40 gtts/min

Nov. 20,09 10:45 am

#9 D5LR 1 L @ 40 gtts/min

Nov. 20,09 5:00 pm

#10 D5LR 1 L @ 40 gtts/min

Nov. 20.09

#11 D5LR 1 L @ 40 gtts/min

V. A. ANATOMY AND PHYSIOLOGY

B. PATHOPHYSIOLOGY Dengue Fever Definiton: Is a disease caused by a family of viruses that are transmitted by mosquitoes. Predisposing factors: Gender both Precipitating factors: Sanitation Environmental DENGUE FEVER Causative agent: DENGUE VIRUS TYPES 1,2,3,4 Chikungunya virus INCUBATION PERIOD: 6 days to one week SOURCE OF INFECTION : 1. the Aedes Aegypti/ household mosquito 2. the infected person. MILD w/ slight fever w/ or without petechial hemorrhage 3 CLASSIFICATIONS MODERATE w/ high fever less hemorrhage no shock SEVERE, FRANK w/ flushing sudden high fever severe hemorrhage sudden drop of temp shock , death

CLINICAL MANIFESTATIONS: 1st 4 days Febrile / invasive temp Headache later flushing 4th- 7th days toxic or hemorrhagic stage lowering of temp severe abdominal pain freq bleeding of GIT 7th-10th days Convalescent/ recovery stage generalized flushing w/ interventing areas of blanching appetite regained and BP already stable

vomiting epistaxis conjunctival infection

hematemesis or melena unstable BP narrow pulse pressure Shock

DIAGNOSTIC TEST Tourniquet test (rumple-lead test) MEDICAL MGT: 1. Paracetamol for fever, analgesic for headache, does not give aspirin for shock. 2. Fluid replacement 3. ORESOL 1. 2. 3. 4. NURSING MGT: Tourniquet test Position patient on dorsal recumbent for shock Elevate position for hemorrhage DIET: low fat, low fiber, non irritating , non carbonated

VI. DOCTORS ORDER DATE/TIME 11-18-09/12:30 am DOCTORS ORDER Please admit under the care of Dr. Sabal Problem: Fever Temperature: every 4 hrs. No chocolate colored foods RATIONALE OF ORDER For observation and treatment To closely monitor temp. for any increase or decrease. To identify if there is blood in the stool.

Venoclysis with D5LR @ 40 To start administration of IV gtts/min and meds. CBC taken @ OPD U/A Repeat CBC @ 6am Meds: omeprazole 40 mg IVTT now PCM 500 mg tab every 4 hrs. >37.8 degree Celsius I and O every shift Monitor V/S every 2 hrs. Relay labs. To AP Refer unusualities 11-18-09/6:00 am IVF TF with D5LR @ SD For chest xray PA Isoprinosine 500mg BID Ranitidine 150 mg BID Fern-C BID 11-19-09/12:05 am Repeat platelet count exam To inform AP on lab results for evaluation. To indicate deviation from normal and note immediately. To follow up electrolytes and avoid imbalances. To determine if lungs are normal. To treat viral infection To neutralize acid in the stomach. To boost immune system. To monitor platelet count

To determine if platelet is within normal value. To relieve epigastric pain To relieve fever

To determine fluid and electrolytes balance.

TF D5LR 1L @ 40 gtts/min 3:00 pm 11:00 pm 11-20-09/7:00 am 3:00 pm 11:00 pm No new doctors order No new orders order No new orders order No new orders order No new orders order

increase or decrease. To maintain fluid and electrolyte supplements To consider continuation of therapy To consider continuation of therapy To consider continuation of therapy To consider continuation of therapy To consider continuation of therapy

Name: D. L. PR:89 bpm

VII. NURSING SYSTEM REVIEW CHART Date: November 18,2009 BP: 110/90 mmHg Temp: 38.9 C RR: 26 cpm Weight: 58.9 kg.

EENT: [ ] impaired vision [ ] blind [ ] pain [ ] reddened [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion [ ] teeth Assess eyes, ears, nose, throat for abnormality [x ] No problem RESP: [ ] asymmetric [ ] tachypnea [ ] apnea [ ] rales [ ] cough [ ] barrel chest [ ] bradypnea [ ] shallow [ ] rhonchi [x] sputum [ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic Assess resp. rate, rhythm, depth, pattern, breath sounds, comfort [ ] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [x] pain Assess heart sounds, rate rhythm, pulse, blood Pressure, circ., fluid retention, comfort [ ] no problem GASTROINTESTINAL TRACT: [ ] obese [ ] distention [ ] mass [ ] dysphagia [ ] rigidty [x ] pain Assess abdomen, bowel habits, swallowing, Bowel sounds, comfort [ ] no problem GENITO URINARY AND GYNE: [ ] pain [ ] urine color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] noctoria Assess urine freq., control, color, odor, Comfort / Gyn-bleeding, discharge [x] No problem NEURO: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizure [ ] lethargic [ ] comatose [ ] vertigo [ ] tremors [ ] confused [ ] vision [ ] grip Assess motor function, sensation, LOC, strength Grip, gait, coordination, orientation, speech [x] no problem MUSCULOSKELETAL and SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechie [x] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [x ] poor turgor [ ] cool [ ] deformity [ ] wound [ ] rash [ ] skin color [ x] flushed [ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic [ ] Moist Assess mobility, motion gait, alignment, joint function/ Skin color, texture, turgor, integrity [ ] no problem

Pale conjunctiva Pale mucous membrane Productive cough Dry lips Body Temp: 38.9 C Poor appetite Epigastric pain Dry and pale skin Hot skin IVF

Body weakness Limited ROM

Infiltrated site

VIII. NURSING ASSESSMENT ll SUBJECTIVE

COMMUNICATION [ ]hearing loss Comments [ ]visual changes wala man koy problema sa akong pananaw og pandungog as verbalized by the pt. [ x ]denied

OBJECTIVE
[ ] Glasses [ ] Contract lens [ ] languages [ ] hearing aide

R L Pupil size: 3mm both eyes [ ]speech difficulties Reaction: (PERRLA) Pupil is Equally Round
Reacted to Light Accommodation

OXYGENATION [ ] Dyspnea Comments [ ] Smoking history inig mu-ubo ko kay nay mugawas na green na plema as verbalized by the pt.
[x] Cough [x] Sputum [ ] Denied

Resp. [ x ] Regular [ ] Irregular Describe: Pts respiratory rate is within normal range 26cpm
R Right lung is symmetrical to left lung L Left lung is symmetrical to right lung

CIRCULATION [ ] Chest pain [ ]Leg pain

[ ]Numbness of

Extremities
[x]Denied

Heart Rhythm [ x ] regular [ ] irregular Comments Ankle Edema: okay raman ako pag-ginhawa Wala man pod ko galisod as Pulse Car. Rad. AP Fem* Verbalized by the pt. R + + + L + + + + Comments: all pulse are palpable *If applicable

NUTRITION Diet: DAT. No chocolate colored foods [ ]N [ ]V Comments gakawalaan ko gana mukaon As verbalized by the pt. Character [ x ] Recent change in Wt., appetite [ ] Swallowing Difficulty [ ] Denied ELIMINATION Usual bowel pattern 1 x a day [ ] Constipation Remedy
[ ] Urinary Frequency

[ ] Dentures

[ x ] none

Full patient Upper : Lower:

[ ]

Partial
[ ]

with
[ ]

[ ]

[ ]

[ ]

4 x a day [ ] urgency [ ] dysuria [ ] Hematuria

Comments Pt. is unable to recall Bowel sound: Hypoactive sounds 2 mins. Abdominal Distention

Date of last BM not recalled [ ] Diarrhea Character

[ [ [ [

] incontinence ] Polyuria ] foly in place ] Denied

Present [ ] yes [ x ] no Urine* (color, consistency, odor) yellow colored urine, aromatic odor and moderate amount Briefly describe the patients ability to follow treatments ( diet, medication, etc.) from chronic health problems ( if present) Pt. is cooperative on following treatment.

MGT. of health & Illness: [ ] Alcohol [ ] Denied (amount, frequency) Pt. has no history of any alcoholic events being take place. [ ] SBE last Pap Smear: LMP: not recalled Not undergone papsmear and SBE SKIN INTEGRITY [ x ] Dry Comments [ ] Itching lain lage ako pamit kau gauga Og luspad as verbalized by the pt. [ ]Other [ ]Denied

[ x ] Dry [ ] Flushed [ ] Moist

[ ] cold [ x ] warm [ ] cyanotic

[ ] pale

*rashes, ulcers, decubitus ( describe size, location, drainage) : Dry skin is being noted

ACTIITY/SAFETY [ ] Convulsion Comments [ ] Dizziness makalakaw man ko pero Kinahanglan naa koy kauban As verbalized by the pt. [ x ] Limited motion of joints Limitation in Ability to [ x ] Ambulate [ ] Bathe self [ ] Other [ ] Denied COMFORT/SLEEP/AWAKE: [ x ] Pain Comments (location grabe jud kasakit akong tiyan As verbalized by the pt. frequency remedies) [ ] nocturia [ x ] sleep difficulties galisod ko og tulog inig Gabie kay tugnaw gataki-

[ ] LOC and orientation: pt. is oriented to

date, time, place, and person. Gait: [ ] walker

[ ] cane [ ] others

[ x ] Steady [ ] Unsteady [ ] Sensory and motor losses in face or

extremities : Sensory and Motor loss limited

[ x ] ROM limitations:

Pt. is able to walk but with assistance

[ x ] Facial grimaces [ x ] Guarding [ x ] Other signs of pain: pain scale 10/10 [ ] Siderail release form signed (60 +

years)

Gan ko as verbalized by The pt.

[ ] denied

COPING Occupation: none Members of household: 4 members of the family Most supportive person: Mrs. Evelyn (mother)

Observed non-verbal behavior: the significant others are supportive and attends the needs of pt. The person and his phone number that can be reached any time: not given

IX. NURSING MANAGEMENT A. IDEAL NURSING MANAGEMENT

NURSING DIAGNOSIS: Infection, risk for Risk factors may include Inadequate secondary defenses, e.g., decreased hemoglobin, leukopenia, or decreased granulocytes (suppressed inflammatory response) Inadequate primary defenses, e.g., broken skin, stasis of body fluids; invasive procedures; chronic disease, malnutrition Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL: Risk Control (NOC) Identify behaviors to prevent/reduce risk of infection. Immune Status (NOC) Be free of signs of infection, achieve timely wound healing (if present).

ACTIONS/INTERVENTIONS Infection Protection (NIC) Independent Perform/promote meticulous handwashing by caregivers and patient.
R: Prevents cross-contamination/bacterial colonization. Note: Patient with severe/aplastic anemia may be at risk from normal skin flora.

Maintain strict aseptic techniques with procedures/wound care.

R: Reduces risk of bacterial colonization/infection.

Provide meticulous skin, oral, and perianal care.

R: Reduces risk of skin/tissue breakdown and infection.

Encourage frequent position changes/ ambulation, coughing, and deep-breathing exercises.

R: Promotes ventilation of all lung segments and aids in mobilizing secretions to prevent pneumonia.

Promote adequate fluid intake.

R: Assists in liquefying respiratory secretions to facilitate expectoration and prevent stasis of body fluids (e.g., respiratory and renal).

Stress need to monitor/limit visitors. Provide protective isolation if appropriate. Restrict live plants/cut flowers.
R: Limits exposure to bacteria/infections. Protective isolation may be required in aplastic anemia, when immune response is most compromised.

Monitor temperature. Note presence of chills and tachycardia with/without fever.

R: Reflective of inflammatory process/ infection, requiring evaluation and treatment. Note: With bone marrow suppression, leukocytic failure may lead to fulminating infections.

Observe for wound erythema/drainage

R: Indicators of local infection. Note: Pus formation may be absent if granulocytes are depressed.

Collaborative Obtain specimens for culture/sensitivity as indicated.

R: Verifies presence of infection, identifies specific pathogen, and influences choice of treatment.

Administer topical antiseptics; systemic antibiotics.

R: May be used prophylactically to reduce colonization or used to treat specific infectious process.

IDEAL NURSING CARE PLAN NURSING DIAGNOSIS: Nutrition: imbalanced, less than body requirements May be related to Failure to ingest or inability to digest food/absorb nutrients necessary for formation of normal RBCs Possibly evidenced by Weight loss/weight below normal for age, height, and build Decreased triceps skin-fold measurement Changes in gums, oral mucous membranes Decreased tolerance for activity, weakness, and loss of muscle tone DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL: Nutritional Status (NOC) Demonstrate progressive weight gain or stable weight, with normalization of laboratory values. Experience no signs of malnutrition. Demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight. ACTIONS/INTERVENTIONS Nutrition Therapy (NIC) Independent Review nutritional history, including food preferences
R: Identifies deficiencies, suggests possible interventions.

Observe and record patients food intake.

R: Monitors caloric intake or insufficient quality of food consumption.

Weigh periodically as appropriate (e.g., weekly).

R: Monitors weight loss and effectiveness of nutritional interventions.

Recommend small, frequent meals and/or between-meal nourishment.

R: May reduce fatigue and thus enhance intake while preventing gastric distension. Use of Ensure/Isomil or similar product provides additional protein and calories.

Suggest bland diet, low in roughage, avoiding hot, spicy, or very acidic foods as indicated.
R: When oral lesions are present, pain may restrict type of foods patient can tolerate.

Have patient record and report occurrence of nausea/ vomiting, flatus, and other related symptoms such as irritability or impaired memory.
R: May reflect effects of anemias (hypoxia, vitamin B12 deficiency) on organs.

Collaborative Consult with dietitian.

R: Aids in establishing dietary plan to meet individual needs.

Monitor laboratory studies, e.g., Hb/Hct, blood urea nitrogen (BUN), prealbumin/albumin, protein, transferrin, serum iron, vitamin B12, folic acid, TIBC, serum electrolytes.
R: Evaluates effectiveness of treatment regimen, including dietary sources of needed nutrients.

Administer medications as indicated,e.g.: Vitamin and mineral supplements, e.g., cyanocobalamin (vitamin B12), folic acid (Folvite), ascorbic acid (vitamin C);

Nursing Diagnosis: risk for imbalanced Fluid volume include risk factors inadequate fluid intake, bleeding, hyperthermia Possible evidenced by: [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL: Risk Control (NOC) Demonstrate adequate fluid balance as evidenced by stable vital signs, palpable pulses, normal skin turgor and no edema present. Actions/Interventions Independent: note clients age, current level of hydration.
R: this is to provide information regarding ability to tolerate fluid level.

Measure and record I/O.

R:To monitor loss fluid

Note presence of vomiting, liquid stool

R:To include losses in output calculations

Calculate fluid balance(intake>output or output>intake)

R:To prevent fluctuations/imbalances in fluid levels

Auscultate BP, calculate pulse pressure

R:PP widens before systolic BP drops in response to fluid loss.)

Weigh daily or as indicated and evaluate changes

R:Because these may relate to fluid status

COLLABORATIVE: Administer IV fluids as prescribed

R: to promote fluid management

Assist with rotating tourniquet phlebotomy, dialysis, or ultrafiltration

R: to correct fluid overload situation.

B. ACTUAL NURSING MANAGEMENT (SOAPIE FORM) S O A P I init lage ako lawas og sakit pud ako ulo as verbalized by the patient.
Increased in body temp. 38c Flushed skin, warm to touch chills

Hyperthermia related to illness At the end of 30 min. patients temp. will be lower down from 38C to 37.5C Provided tepid sponge bath May help reduce fever.

Provided adequate fluid intake

To prevent dehydration

Reassessed body temperature q 15 To determine the effectiveness of the min. interventions done. Monitored clients noted shaking chills. temperature, To prevent further complications

Instructed client to have a bed rest.

to reduce metabolic demands/oxygen consumption Collaborative: To reduce fever and to restore normal Administer antipyretic medication; body temperature. e.g., paracetamol At the end of the shift, patients body temperature was lowered down from 38c to 37.5c

S O

A P I

Sakit ako tiyan as verbalized by the patient As evidenced by: Facial grimace Guarding Pain scale 7/10 Acute Pain related to At the end of 30 min the patient will be able to verbalize method that relief pain Independent: -Encouraged use of relation technique such as deep breathing exercise To minimize pain -Provided small frequent meals To avoid abdominal pain -Provided position of comfort To reduce pain and provide comfort -Encouraged adequate rest periods To prevent fatigue Dependent: - Administer medication as indicated

To reduce pain and muscle spasm At the end of 30 minutes the patient was able to verbalized method that provide relief.

S O

Pila nako ka-adlaw na wala na kalibang as verbalized by the pt. As evidenced by:
Hypo-active bowel sound

A P

Constipation related to poor eating habit and insufficient fiber intake At the end of 30min. pt wil be able to verbalize understanding about proper life style modification

Independent:

-Encouraged activity and exercise as tolerated May reduce potential for constipation by improving stool consistency and to stimulate contraction of intestine -Encouraged adequate fluid intake and high fiber ,fruit juices To improve consistency of stool, facilitate passage through colon -Provided information about relationship between diet and exercise To provide proper way of elimination -Encouraged adequate rest periods To prevent fatigue At the end of 30 min the patient was able to verbalized understanding about proper life style modification.

S O

Kapoy kayo ako lawas as verbalized by the patient As evidenced by:

Generalized body weakness Assisted in walking

A P

Activity Intolerance related to body weakness At the end of 30min. pt wil be able to indentify tecniques to enhances activity toleralnce

Independent:

-Encourage patient to maintain positives attitude such as relaxation technique To enhance sense of well-being -Provide positive atmosphere To minimize fatigue -Provide patient in planning care between rest period and activity To reduce weakness -Plan care with rest periods between activities To reduce fatigue -Assist client to learn and demonstrate appropriate safety measure To prevent injury At the end of 30 min the patient was able to indentified techniques to enhance activity tolerance

X. DRUG STUDY

Drug Name: Classification: Indication: Dosage/route/frequency: Mechanism of action: Contraindications: Adverse eactions: Precautions:

Fern-C Vitamin B complex with vita. C Prevention and treatment of Vitamin C deficiency enhances immune system and resistance to fatigue and muscle weakness. I cap BID P.O Collagen synthesis Renal impairment due to intake of alcohol Drug toxicity and hypersensitivity Note for any intake of medication to prevent autoimmune reaction of physiologic response

Drug Name: Classification: Indication: Dosage/route/frequency: Mechanism of action: Contraindications: Adverse reactions:

Isoprinosine Anti-infectives Treatment of various viral infection 500mg BID x7 a day Inhibit growth of bacteria or kill susceptible pathogenic bacteria. avoid taking without meals transient elevation of urine/serum, uric acid level skin rashes or itching gi upset, nausea, fatigue/malaise, constipation, polyuria proper dosage of time, amount of dosage intake assessing for any drug toxicity. Note for severe psychological drug reactions.

Precautions:

Drug Name: Classification: Indication: Dosage/route/frequency: Mechanism of action: Contraindications:

Paracetamol Antipyretics Mild pain and for fever 500 mg 1 tab q 4 hrs PO Inhibits the synthesis of prostaglandin that may serves as mediators of pain and fever, primarily in the CNS Contraindicated in previous hypersensitivity. Products containing alcohol. Use cautiously in hepatic disease/ renal disease GI hepatic failure, renal failure Neutropenia, leucopenia Rash, urticaria May alter result of blood glucose monitoring Advise pt to avoid alcohol (3 or more glasses per day to avoid risk of liver damage

Adverse eactions:

Precautions:

Drug Name: Classification: Indication: Dosage/route/frequency: Mechanism of action:

Ranitidine Anti-ulcer agents (H2 antagonist) Inhibition of gastric acid secretion stress ulcer on upper GI 150 mg BID x 7 days Inhibits the action of histamine at the H2- receptors site located primarily in gastric parietal cells resulting in inhibition of gastric acid secretion Contraindicated in hypersensitivity. Use cautiously in in renal impairement ( more susceptible to CNS reactions) CNS: confusion, dizziness, drowsiness, hallucination, headache Arrythmia Black tongue, constipation, dark stool Anemia, neutropenia Assess for epigastric and abdominal pain. Monitor CBC with differentiated periodically during therapy

Contraindications: Adverse reactions:

Precautions:

XI. A. REFERRALS AND FOLLOW-UP MEDICATION Client is advice to follow strict compliance of home medications, following strict time and continuous antibiotic treatment followed meds: Fern C, Isoprenosole, Ranitidine RATIONALE: Home medication should be instructed to ensure that the essential pharmacologic response is effective by proper elimination of bacteria and viruses by strict compliance of EXERCISE medications Patient is advice to have relaxation techniques such as Fecal Imagery to a non-pharmacological interrelation being made. Assist client with passive and active range of motion exercise. RATIONALE: Fecal Imagery is a higher form of therapeutic response to ensure a non-dependent response top intervention without the TREATMENT help of pharmacologic indication Patient is advice to follow: Promotion of good rest and avoidance of stressful activities Compliance to medication Practice relaxation techniques to provide a therapeutic response such as medication RATIONALE: Non-pharmacologic approach provides a holistic care and

OUT PATIENT

ensures client with treatment compliance to be very effective. Instruct client for a follow up check up by giving a note with a complete date, specific place and time with reservation of the attending physician to ensure harmonious check-up. RATIONALE: Proper place with the proper time ensures collaborative measures between the client and the hospital staff to ensure that the instructions are being given with an accurate

DIET

information. Client is advice to eat nutritious foods with fresh fruits and vegetables. Increase fluid intake at least 8 glasses per day. Avoid any alcoholic beverages and soda bottled drink. RATIONALE: Optimum quality of vegetables, provide vitamins necessary for growth of clients physiologic needs. Increase fluid intake ensures fluid balance in the body system and essential nutrients for nutritional balance. Alcoholic beverages prevents and be avoided to eliminate waste and junk in the body system.

B. EVALUATION AND IMPLICATIONS After conducting this care study, We were able to appreciate more the essence of utilizing the nursing process in the care and management of my patient. It was indeed a tough job on

conducting this study yet, it gave us a big impact regarding how useful it is in our chosen profession. Nursing really demands a tender loving care attitude. It demands patience and it is calling that cannot be merely taken for granted. Moreover, this care study taught us to stand on our own by not depending on others just to make this. This provides us, the students, a big learning regarding on how well we take care of or patients in the real clinical setting. Most of all, this study teaches the students to provide clients care more efficiently and competently to achieve an effective and quality nursing care.

XII. BIBLIOGRAPHY Medical-Surgical Nursing 11th Edition. Suzanne Smeltzer, Brenda Bare, Janice Hinkle, Kerry Cheever. Volume 1. Pp. 1204 1207

 Nurses Pocket Guide (Diagnoses. Prioritized Interventions, and Rationales) 11th Edition. Mrilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr PPDs Nursing Drug Guide 2007 Edition http://www.emedicine.com/MED/topic850.htm