MANILA TYTANA COLLEGES Pres. Diosdado Macapagal Blvd.

, Metropolitan Park, Pasay City

NURSING PROCESS Area: PCGH TITLE: Dengue Hemorrhagic Fever Stage II

Submitted by: CA-9 Leader: Aldon, Marlo Dianne Members: Arenas, Kier Alfonso, Maja Advincula, Jerome Ampatuan, Anhara Andrion, Leigh Alcantara, Paolo Bedua, Darryl Joyce Balangue, Shelly Campos, Carlos Joseph Divinagracia, Joannie

MANILA DOCTORS COLLEGE Pres. Diosdado Macapagal Blvd., Metropolitan park, Pasay City NURSING PROCESS Revised New Data Sheet Guide I. ASSESSMENT A. General Data

Patients Initial: L.J.A Address: Pasay City Informant: J.F (cousin) Age: 30 Date of Admission: Sept. 4, 2011(11:35 pm) Sex: Female No. of Days in This hospital: 2 Order of Admission: September 3 2011 Date of Birth: 9/04/1981 Place of Birth: Cotabato Civil Status: Single Occupation: Warehouse Staff Primary Language Spoken: Tagalog Educational Attainment: College graduate Religious Orientation: Roman Catholic Health Care Financing and Usual Source of Medical Care: NONE B. Chief Complaints Nahihilo ako at nilalagnat, masakit ang katawan ko, at madami akong rashes sa tiyan, sa braso ko at mga binti, as verbalized by the patient. C. History of present illness Four days prior to confinement the patient together with her cousin went to a mall to eat there and stay at the Seaside. Two days prior to confinement, the patient experience fever with the temperature of 38.8 C and body weakness. Had consultation on the OPD of PCGH, urine analysis and CBC was done with a low platelet count of 102 x109/L and was advised to be admitted in the hospital. One day prior to confinement, the patient had a persistent fever and body weakness and take paracetamol to relieve the fever. Few hours prior to confinement the patient had persistent high grade fever of 39C, fatigue and headache. Also abdominal pain is experienced by the patient but no bleeding noted. The patient was admitted under the service of Dr. Padilla. D. Past History 1. 2. 3. 4. 5. 6. 7. 8. Childhood Illness/es: None Adult Illness/es: None Immunizations (date): fully immunized ( date unrecalled) Previous Hospitalizations (Dates): None Operation/s (include year): None Injuries (include year): None Medications taken prior to confinement (6 months): Ascorbic Acid and Paracetamol Allergies: None

E.

Systems Review Gordons Eleven Functional Areas (more than 3 years old patient only)

1. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN The patient rate her health as 10 out o 10, she consider healthy herself healthy because she is emotionally prepared and can easily adopt t her environment especially at work. She believes that health is important because she consider it as puhunan /investment; to be able to earn money. The company where she works required her to do yearly annual examination. She has never been confined. She does not perform breast self examination. She practice her personal hygiene by taking a bath 2 times a day, trims her nails twice a week, brusher her teeth 2 time a day and uses soap to clean genital area. Her last dental check was last April 2011. She does not use any deodorant because it darkens her armpit. . She isnt a smoker and an alcoholic according to her. They have every day supply of water for drinking and dispose their garbage through plastic which is collected everyday by a truck.

The patient rate herself as 6 out of 10, she can no longer go on work due to her confinement to hospital. She does not perform bathing; she does not brush her teeth as instructed by her doctor to prevent bleeding of gums from the bristle of the brush. She uses water to rinse her mouth and act as mouth wash. 2. NUTRITIONAL AND METABOLIC PATTERN The patient takes for about 1000 ml of water a day and urinates 5 times a day. She is not fully aware of proper nutrition all she knew is when she doesnt like the food she would not eat or will throw it up. She likes rice more than the dish. She also likes to eat fruit like banana and apple, vegetable like ampalaya. Their food is prepared by their maid; they eat together in their round table. She include herself in food budgeting and expenses in to her uncles house. Her appetite is in moderate limit. She has no experience of any food discomfort or restriction. She has good skin turgor, no lesions, with scar in her right deltoid part measuring of 4 cm in length from her childhood immunization, and smooth moistened skin. She has complete teeth with 32 in number, with pit dental caries in 25, 24 and 8.

The patient was instructed to increase her fluid intake. She is able to consume 2000 to 3000 ml of bottled water a day. The patient is on DAT (Diet as Tolerated) and EDCF (Except dark color food). Her food is now prepared and provided by the hospital. Her doctor advises her not to brush her teeth to prevent bleeding in her gums.

3. ELIMINATION PATTERN The patients defecate every other day. She describes her stool as hard, brown in color and bulky stool. There is no presence of pain or any discomfort during her defecation. She urinate 5-7 times a day approximately 50-70 cc per urination, described it as yellow in color, clear and ammonic in odor. She has no pain or any discomfort in urinating and can able to with hold her urine. She has no excessive perspiration without body odor.

The patient defecates every day. She describes it as soft, bulky, dark brown in color. Without discomfort in defecating or any restriction. She urinates 10 times a day approximately 50-70 cc per urination with a yellow in color, clear and has an ammonia odor. No pain or any discomfort felt. 4. ACTIVITY-EXERCISE PATTERN The patient usual day is waking up in the morning to clean the house, preparing for her whole day job that starts in 9 am to 6pm. She doesnt engage herself in activities such as sport or exercise, because of her busy schedule as a warehouse staff nurse. Her energy is enough to her everyday work. She spends her spare time in their room for staff at work to sleep and it satisfies her body and regains her energy.

The patient usual day like is resting, sleeping and eating. She does not do much because she is advice to rest. She is experiencing body weakness and light headedness. No exercise or any heavy activities done.

5. SLEEP-REST PATTERN The patient sleeps for 8 straight hours. She sleeps at 11 or 12 pm and wakes up at 6am. She feels refreshed and energetic. She has 1 pillow use. Whenever she has difficulty of sleeping she watches TV until she fall asleep. She takes a nap in the afternoon in her break time at her work.

The patient sleeps for 8 hours with interruption due to vital signs taking. But can able to go back to sleep.

6. COGNITIVE-PERCEPTUAL PATTERN The patient can read and write without any difficulties. There is no problem in hearing; both ears can clearly hear sounds. No change of memory can still recall past events. No change in taste or smelling. She has a good relationship towards her co workers.

The patient can read and write without any difficulties. Both ears can hear clearly. Can recall recent event and oriented by time, date, and place. No change in taste and smell.

7. SELF-PERCEPTION AND SELF-CONCEPT PATTERN She describes herself as a simple and passionate person. She feels good towards herself and is able to express herself towards others. Her relationship towards her family is good; they support her and are concern about her. She expresses herself towards others through action and words. For her plans after 5 years she wanted to be successful in her career and be able to invest a small business. She is in a calm mood. The things that make her angry or annoyed are by judging her without knowing her. In times where she feel

angry and annoyed towards someone she confronts that person and saying asking or saying that she dislike what he or she did towards her.

She still feels goods towards herself and is able to express her mood towards others through action. She now wants to be cured and discharge so she could be able to go back to work.

8. ROLE-RELATIONSHIP PATTERN The patient lives together with her uncle and cousins. She values her second cousin more than others, but gives equal love towards them. She communicates with her family in province and has a good relationship. Whenever she and her family faces trials and problems they talk to each and make a conference like meet to know what others have in mind. As the first child of their parents she manages to provide money to her family in province. Her family is independent in terms of making decisions and she knew she can provide solution in every problem that they may encounter. She has a good relationship towards her co-workers. Her income is enough for her everyday expenses.

The patient is close to her second cousin because she is the one who take care of her while in the hospital. She still manages as the role of the first born. 9. SEXUALITY-REPRODUCTIVE PATTERN The patient expresses herself by action and affection. Last menstrual period was on Aug. 1st week of the month. No present problem regarding menstruation. 10. COPING STRESS TOLERANCE PATTERN She describes a stressful event where there is too much people that violates her privacy. She manages this problem by consulting to her mother or any elder to ask for advice and release her thoughts towards her second cousin. When she is tense she thinks of the problem and tries to solve it in order for her to time to sort things. There are no big changes that happened to her these last few years. She can still manage her problem well with the help of her cousins and uncle and supported by her parents. 11. VALUE-BELIEF PATTERN The patient described a healthy person if the person is fit and has intact immune system. She values her health much and is comfortable that her immune system wont fail her. She is actively participating in church every Sunday. She is moderately active socially at their place and at work. The patient considers someone as a healthy person when he/she can tolerate activities and recovers easily from sickness. She was not able to go to church much due to her health status and for this reason, she just prays where she is esp. at night to maintain her relationship with God.

D. Family Assessment (tabulated) Genogram : Attached NAME IA LM CA JB RA RELATION Uncle 2nd Cousin 1st Cousin Maid 1st Cousin AGE 52 23 23 20 4 SEX M F M M F OCCUPATIONAL None Warehouse Staff None Maid N/A EDUCATIONAL ATTAINMENT College Graduate College Graduate College Graduate High School Undergraduate N/A

E. Heredo- Familial Illness Maternal: None Paternal: None F. Development History (Psychosocial by Erickson, Psychosexual by Freud, Cognitive by Piaget, Moral by Kohlberg and Spiritual by Fowler) Developmental History Theorist Jean Piaget Age 30 Task Formal operation Client Description Client is able to think both logically and abstractly by examining the effects of her actions to a certain situation and being able to determine its effects on the situation. She is also able to see the alternatives that she can do in the situation. She is a workaholic person and she likes to make friends in her workplace. She is very involved in her work and works 7 days a week. She has a close relationship with his relatives and still keeps in touch with her relatives in the province. The patient also lives with her uncle.

Erik Erikson

30

Generativity versus Stagnation

Lawrence Kohlberg

30

Post conventional

Client is able to use her moral judgment in facing her problems

and situations in her Daily life and in her work place Sigmund Freud 30 Genital Energy is directed toward full sexual maturity and function and development of skills needed to cope with the environment. As being a woman the client is open in terms of contraceptives with her partner. She is faithful to her religion and believes in God, she is also strong in her beliefs and to her commitment in her religion but also is strong in other beliefs and values in which her parents have taught to her.

James Fowler

30

Individuative reflective faith

G. Physical Examination (September 5, 2011) Height: 157.48 cm Weight: 105 lbs Body Mass Index: 19.2 Vital Signs: Temperature: 36C PR: 76 bpm RR: 22 cpm BP: 90/60 Regional Examination: A. Skin I: P: Flushed skin with petechiae all over the body No edema Skin temperature is uniform throughout the body The skin on the soles and axilla are moist Good skin turgor

B. Nails I: Convex curvature Pink fingernail and toe beds Intact epidermis Smooth texture Capillary refill is about 3 seconds

P:

C. Head and Face I: D. Eyes I: E. Ears Hair on the eyebrows are evenly distributed Eyebrows are symmetrically aligned with equal movements Eyelashes are evenly distributed, curled slightly outwards The patients head is round and has smooth skull contour Uniform consistency of skull Symmetrical nasolabial folds Face is flushed and with petechiae Symmetric facial movements Absence of nodules and masses

P:

I: F. Nose I: Proportionally located in the midline of face Patent and without discharge Ears are both symmetrical and aligned with the outer canthus of the eye Normal voice tones audible

G. Mouth and Pharynx I: Lips are dark pink Presence of tooth decays Tongue is in central position

Tongue move freely and not tender

H. Neck I: Coordinated and smooth movements with decreased strength Equal size and shape Palpable lymph nodes

P:

I. Spine I: Spine is vertically aligned at the posterior part of the body Spinal column is straight Right and left shoulders, and hips are of the same height

J. Thorax/Lungs I: AP:Transverse diameter is 1:2 Symmetrical chest expansion No adventitious breath sounds upon auscultation

A:

K. Cardiovascular/Heart I: P: A: Jugular veins are not distended Aortic, Pulmonic, Tricuspid pulses are palpable Regular rhythm of heartbeat and no murmurs upon auscultation

L. Breast Client refused. M. Abdomen Client refused. N. Extremities I: Petechiae are present in the upper and lower extremities Equal size of extremities

P:

Uniform temperature No edema Capillary refill 3 seconds

O. Musculoskeletal: I: Muscles are firm Decreased muscle strength Pain upon palpation

P:

P. Genitals Client refused. Q. Rectum and Anus Client refused. R. Neurologic Exam The patient can speak audibly and she has no problems with it The patient is coherent and oriented to person, time and place The patient could immediately recall recent and remote events Level of consciousness scored 15 on Glasgow Coma Scale Corneal reflex, Patellar reflex is present

REMINDERS: Strictly to be performed only with Clinical Instructors Supervision and ask parental, patient & significant others consent, on the following: Breast, Genitals, Rectum, and Anus No Internal Exam on Pregnant women allowed

II. PERSONAL / SOCIAL HISTORY Habits: Watching TV Rank in the family: Eldest Vices: none Lifestyle: Active Social Affiliation: none Clients usual day like:

Travel (for at least 6 months only): none Educational Attainment: College Graduate

The patient wakes up in the morning at around 6:00 AM. She eats her breakfast everyday and bathes herself. At around 7:30 then travels to work. She starts working at around 9:00 AM. After working in the morning, she takes her break 12:00 PM to eat her lunch then take a power nap. Then at 1:00 PM she resumes working. Then finish working at around 6:00 PM. After 1 hour of travel time, she got home at around 7:00 PM. After that she eats her dinner then sleeps at around 11:00 PM. III. ENVIRONMENT HISTORY (living/neighbourhood circumstances) The patient lives in a medium-sized rented apartment with 1 bedroom with its own bathroom. It comes with its own kitchen. It has adequate lighting but it has only 1 window. It has only 1 bed and 2 electric fans. Their garbage refuse is

collected every day. There is no open sewer anywhere. Her workplace is adequate in lighting and ventilation because there are many windows. They have annual physical examinations. IV. OB/GYNE HISTORY For FEMALES only

Menarche (age): 12 years old When: Not Recalled Amount and Characteristics: fully soaked, 3 pads a day Duration: 3-4 days Associated Symptoms: back pain V. PEDIATRIC HISTORY: N/A MATERNAL AND BIRTH HISTORY Birth date: Birth weight: Type of Delivery: Condition after birth: Hospital:

Mother Complications of delivery: Anesthesia during labor: Exposure to Teratogenic Agents During Pregnancy: Neonates Only Neonates history: Type of feeding:

XI.

ONGOING APPRAISAL

L.J.A. who is 30 years of age, was admitted on September 4, 2011, with the chief complaint of having an intermittent fever and headache with fatigue for three days. She is under the service of Dr. Padilla. Secures consent for admission and management with a diagnosis of Dengue Hemorrhagic Fever Stage II. Day One:

On the first day of appraisal Ms. L.J.A. she was received awake on bed in a semi fowlers position with relatives at bedside. He had ongoing IV fluid on left metacarpal vein; on #1 PNSS 1L on KVO regulated and infusing well. She was on diet as tolerated and EDCF diet. CBC is taken every 12 hours. Vital Signs: Temperature: 38.5C PR: 87 bpm RR: 20 cpm BP: 90/60

Day two:

On the second day, she was received on bed in supine position with relatives at bedside with ongoing IVF on left metacarpal vein; still on #3PNSS 1L regulated and infusing well. CBC was taken at 8am. Vital Signs: Temperature: 36.5 PR: 75 RR: 20 BP: 90/60mmHg Ms. L.J.A. encouraged increasing her fluid intake. Due medications are given.

Day three:

On the third day, Ms. L.J.A. was received sitting upright on bed in high Fowlers position with relatives at bedside. She still has ongoing IVF on left metacarpal vein; #6 PNSS 1L regulated and infusing well. She was on diet as tolerated and except dark color foods. Vital Signs: Temperature: 36.7 PR: 80 RR: 20 BP: 90/60 mmHg

XII.

DISCHARGE PLAN

Note: This is a hypothetical discharge plan for during the interviewers shift the client does not have an order from his physician to be discharged. This was made solely for the purpose of completing the advised guide made by our school in making a Nursing Process. M- Medications E- Exercise T- Treatment Advice patient to take medications as ordered by the physician and monitor the temperature. Encourage bed rest when she feels stressed. Encourage patient to resume light daily activities at home and avoid engaging in stressful activities. Intake of appropriate medications such as vitamin supplement to increase protection mechanism of the immune system. Instruct patient to take home medications as ordered by the doctor.

H- Health Education Discuss the possible source of infection of the disease. Advice patient to follow proper body hygiene and to maintain cleanliness in their house so that dengue this time would be prevented and encourage to throw stagnant waters that may cause dengue. Never stocked water in a container without cover.

O- OPD follow- up D- Diet Instruct patient to increase fluid intake and avoid dark color foods. Instruct the family members to give the client protein rich foods such as meat, fish, eggs and nuts, vitamin K rich foods such as green leafy vegetables, vitamin C rich foods(guava and tomatoes and other citrus fruits), carbohydrates rich food (breads and rice) Instruct patient to come back after a week at the OPD for follow up check-up. Untoward signs and symptoms must be immediately reported to the physician.

S- Signs and Symptoms

Advice patient to note untoward signs and symptoms such as fever, vomiting, nausea. Take medications as ordered by the doctor and rest when these signs and symptoms appear. If not relieved, immediately go to a hospital.