Case Study

Capitol University
College of Nursing
Cagayan de Oro City
A Case Study on
DENGUE SEVERE
In Partial Fulfillment of the requirement of RLE 109 – Northern Mindanao Medical

Center
Second Rotation (Pediatric – Dengue Ward)
Presented to:
Ms. Fredelina S. Chua, RN. MN
Presented by:
Matthew Burgos
Tyron Chua
January 2020
ACKNOWLEDGEMENT
We would like to extend our great gratitude to the following people who took part
in the success of this study.
First, to our Almighty God, for giving us the knowledge and guidance that enabled
us to complete the task. We thank God for giving us lessons in life that we are able
incorporate in our daily lives. We are ever thankful for his grace and love.
To our Clinical Instructor, Ms. Fredelina S. Chua, RN, MN for her ever supportive
role in this journey. Also for her determination and patience during our discussions and
duties has helped us mold us into our better selves.
To our PCI/Head nurses, Ms. Neka Francis for sharing her time with us to learn
and for the motivation she has given us.
To the staff of Northern Mindanao Medical Center, Pediatric – Dengue Ward for
allowing us the opportunity to meet with our clients and have given us time to learn. With
their assistance, it enabled us to be equipped with various set of skills and learn that there
is a different world out there in need of care.
To the client and their family, we are thankful for the cooperative relationship
towards us and showing us appreciation.
To our friends, family and others who served as inspiration to strive and continue
embarking on this journey, thank you for providing us the adequate amount of love you
have given us.
TABLE OF CONTENTS
Acknowledgement ii
Abstract 1
Introduction 2
Background of the study 5
Scope and Limitations of the study 6
Significance of the study 7
Objectives of the study 10
Patient’s Profile 12
Health Pattern Assessment & Health History 13
Physical Assessment 17
Developmental Data 24
Anatomy & Physiology 28
Pathophysiology 34
Diagnostic Tests 35
Medical Management 49
Nursing Management 54
Discharge Plan 57
Evaluation, Results, Discussion 59
Related Learning Experience 60
Definition of Terms 61
Bibliography 62
ABSTRACT
This is a case study of a 6 years old female with a diagnosis of Dengue Severe. A
thorough assessment was done in order to create a visualization of the disease process,
the etiology and pathophysiology of the disease, diagnostic and laboratory evaluations
were carefully studied in contrast to the disease process and above all, client-oriented
nursing care plans were created. Nursing Care Plans were significantly chosen according
to the immediate need of the patient.
Once the care is provided, nursing activities and the use of the nursing system are
evaluated to get an idea about whether the mutually planned goals were met or not. Thus
the theory could be successfully applied into the nursing practice. The author was able to
identify various factors that contributed to the condition by understanding the
pathophysiology of the disease. From this, medical and nursing interventions were
derived.
This study will help the nursing profession both in the clinical area and the
academe. Dengue Severe and similar conditions can have better management. These
occurrences can be prevented given that proper management from the beginning of the
disease.
Introduction
According to World Health Organization, Dengue is fast emerging pandemic-

prone viral disease in many parts of the world. Dengue flourishes in urban poor areas,
suburbs and the countryside but also affects more affluent neighborhoods in tropical
and subtropical countries. Dengue is a mosquito-borne viral infection causing a severe
flu-like illness and, sometimes causing a potentially lethal complication called severe
dengue. The incidence of dengue has increased 30-fold over the last 50 years. Up to
50-100 million infections are now estimated to occur annually in over 100 endemic
countries, putting almost half of the world’s population at risk.
Severe dengue is a potentially fatal complication, due to plasma leaking, fluid

accumulation, respiratory distress, severe bleeding, or organ impairment. Warning
signs that doctors should look for include severe abdominal pain, persistent vomiting,
rapid breathing, bleeding gums, fatigue, restlessness, blood in vomit and others.
Severe dengue (previously known as dengue haemorrhagic fever) was first

recognized in the 1950s during dengue epidemics in the Philippines and Thailand.
Today it affects Asian and Latin American countries and has become a leading cause
of hospitalization and death among children and adults in these regions. The full life
cycle of dengue fever virus involves the role of mosquito as a transmitter (or vector)
and humans as the main victim and source of infection.
The dengue virus (DEN) comprises four distinct serotypes (DEN-1, DEN-2, DEN-3 and
DEN-4) which belong to the genus Flavivirus, family Flaviviridae. Distinct genotypes
have been identified within each serotype, highlighting the extensive genetic variability
of the dengue serotypes. Among them, “Asian” genotypes of DEN-2 and DEN-3 are
frequently associated with severe disease accompanying secondary dengue
infections. The Aedes aegypti mosquito is the main vector that transmits the viruses
that cause dengue. The viruses are passed on to humans through the bites of an
infective female Aedes mosquito, which mainly acquires the virus while feeding on the
blood of an infected person.
Once infected, humans become 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 an infected person for 2-7 days, at approximately the same time that the
person develops a fever. Patients who are already infected with the dengue virus can
transmit the infection via Aedes mosquitoes after the first symptoms appear (during 4-
5 days; maximum 12). The mosquitoes that spread dengue are found in most tropical
and subtropical regions of the world, including many parts of the United States. Ae.
aegypti and Ae. albopictus bite during the day and night.
In humans recovery from infection by one dengue virus provides lifelong

immunity against that particular virus serotype. However, this immunity confers only
partial and transient protection against subsequent infection by the other three
serotypes of the virus. Evidence points to the fact that sequential infection increases
the risk of developing severe dengue. The time interval between infections and the
particular viral sequence of infections may also be of importance.
These mosquitoes typically lay eggs near standing water in containers that hold water,
like buckets, bowls, animal dishes, flower pots, and vases. These mosquitoes prefer
to bite people, and live both indoors and outdoors near people. Mosquitoes become
infected when they bite a person infected with the virus. Infected mosquitoes can then
spread the virus to other people through bites. A pregnant woman already infected with
dengue can pass the virus to her fetus during pregnancy or around the time of birth.
To date, there has been one documented report of dengue spread through breast milk.
Because of the benefits of breastfeeding, mothers are encouraged to breastfeed even
in areas with risk of dengue.
Dengue fever, an Aedes mosquito-borne viral disease, is widespread in Singapore,

but its more lethal forms, dengue haemorrhagic fever (DHF) and dengue shock syndrome
(DSS), referred to as severe dengue, are much less common.
Severe dengue can occur in both adults and children and is life-threatening.
Children are especially at risk. Early detection and proper medical care lower fatality rates
below 1 per cent, according to the World Health Organization (WHO). Severe dengue
initially presents with the common symptoms of dengue fever such as fever, intense
headache, aches and pains, loss of appetite, nausea, vomiting, skin rashes and
leukopenia (reduction in white blood cells). A positive tourniquet test is also a sign of
dengue fever.
After several days, usually 3-7 days after the onset of symptoms, the patient may
display the warning signs of severe dengue. These warning signs typically accompany a
decrease in temperature (below 38 deg C) and include: Severe abdominal pain, Rapid
breathing, Persistent vomiting; Blood in vomit; Fluid accumulation in the body; Mucosal
(gums and nose) bleeding; Liver enlargement; Rapid decrease in platelet count; Lethargy,
restlessness
If the patient develops severe dengue, there will be bleeding spots on the skin and
other parts of the body and leakage of blood plasma. Severe dengue fever can damage
the lungs, liver or heart. Blood pressure can drop to dangerous levels, causing shock and,
in some cases, death. The symptoms of severe dengue include: Severe skin bleeding
with spots of blood on the skin (petechiae) and large patches of blood under the skin
(ecchymoses), black stools, blood in urine (hematuria), severe blood plasma leakage,
respiratory distress, impairment of liver, heart and/or other organs, changes in mental
state with impaired consciousness.
Patients who develop warning signs (in particular lethargy and persistent vomiting)
and those with a low platelet count and high hematocrit (elevated red blood cell count)
are at very high risk of developing very severe dengue, organ failure or even death, says
Dr Chlebicki. Elderly patients with multiple comorbidities (medical conditions) are more
likely to develop severe dengue. Severe dengue may also occur when a person who has
developed immunity to one strain of the virus becomes infected with another strain.
There are four different strains of the dengue virus – DEN 1, 2, 3, 4. In 2013, in
Singapore, over 50 per cent of dengue fever cases were due to the DEN-1 virus strain.
However, since there are four different strains of the dengue virus, a person can
potentially get dengue fever more than once. In 2016, DEN-2 rather than DEN-1 is a
predominant serotype. There is no known cure for severe dengue. A person suffering
from this form of dengue fever may need to be treated in an intensive care unit (ICU).
Treatment will focus on the symptoms and includes the following: Blood and platelet
transfusion, Intravenous fluids for rehydration, Oxygen therapy if oxygen levels are low
“With prompt treatment and care, a patient can recover even from severe dengue.
However, if treatment is delayed and the patient develops shock or multi-organ failure,
the fatality rate rises.”
One dengue fever vaccine, Dengvaxia, is currently approved for use in those ages
9 to 45 who live in areas with a high incidence of dengue fever. The vaccine is given in
three doses over the course of 12 months. Dengvaxia prevents dengue infections slightly
more than half the time. The vaccine is approved only for older children because younger
vaccinated children appear to be at increased risk of severe dengue fever and
hospitalization two years after receiving the vaccine.
The World Health Organization stresses that the vaccine is not an effective tool,
on its own, to reduce dengue fever in areas where the illness is common. Controlling the
mosquito population and human exposure is still the most critical part of prevention
efforts. So for now, if you're living or traveling in an area where dengue fever is known to
be, the best way to avoid dengue fever is to avoid being bitten by mosquitoes that carry
the disease.
The year 2016 was characterized by large dengue outbreaks worldwide. The
Western Pacific Region reported more than 375,000 suspected cases of dengue in 2016,
of which the Philippines reported 176 411 and Malaysia 100 028 cases, representing a
similar burden to the previous year for both countries. Similarly, a 53% reduction in severe
dengue cases was also recorded during 2017. The post Zika outbreak period (after 2016)
has seen a decline of cases of dengue and the exact factors leading to this fall are still
unknown. WHO’s Western Pacific Region has reported dengue outbreaks in several
countries in the Pacific, as well as the circulation of DENV-1 and DENV-2 serotypes. After
a drop in the number of cases in 2017-18, a sharp increase in cases is being observed in
2019. In the Western Pacific region, increase in cases have been observed in Australia,
Cambodia, China, Lao PDR, Malaysia, Philippines, Singapore, Vietnam. DENV-2 was
reported in New Caledonia and DENV-1 in French Polynesia.
Background of the study
Patient X is a 6 years old female, diagnosed with Dengue Severe and was
admitted at Northern Mindanao Medical Center last, she was admitted to the hospital
due to the reason of hypotension.
We were given the opportunity to take this case since it was our designated
patient during our assessment and our first ward duty. Equipping the health care
personnel with appropriate knowledge regarding the disease of the client would help
in providing the best available care that would promote health and wellness of the
client. We researched about Dengue Severe to bring us an insight regarding its signs
and symptoms, diagnostic tests, its causes and intervention of the disease.
This will serve as a guiding tool in proper management of the disease. Dengue
Severe is a serious condition that occurs when a person will have a bleeding spots on the
skin and other parts of the body and leakage of blood plasma. Severe dengue fever can
damage the lungs, liver or heart. Blood pressure can drop to dangerous levels, causing
shock and, in some cases, death.
Severe dengue may also occur when a person who has developed immunity to
one strain of the virus becomes infected with another strain. There is no known cure for
severe dengue. A person suffering from this form of dengue fever may need to be treated
in an intensive care unit (ICU). Treatment will focus on the symptoms and includes the
following: Blood and platelet transfusion; Intravenous fluids for rehydration; Oxygen
therapy if oxygen levels are low. With prompt treatment and care, a patient can recover
even from severe dengue. However, if treatment is delayed and the patient develops
shock or multi-organ failure, the fatality rate rises.
THE SIGNIFICANCE OF THE CASE STUDY IN RELATION TO THE THEME
This study is associated with the Casey’s Model of Nursing and Neuman’s
System Model which provides a comprehensive base to nursing practice. It is
functional in the different fields of nursing. It is considered a general theory with broad
concepts and can be applied in many different situations, rehabilitation, emergency
department, intensive care unit, Pediatric-Dengue Ward Department, and in other
areas where self-care requisites are the driving force for individuals and nurses. It is
extremely contagious, used by nurses at all level from novice to expert in all area of
practice. It is applicable to all of those who need nursing care and also applicable to
all of situations in which individuals cannot meet their entire self-care request.
This case study will help us better understand the process of the disease. This
would bring us information in identifying the primary needs of the patient with Dengue
Severe. By identifying such needs and health problems of the patient associated with
the disease and understanding why such needs and health problems arise, we can
formulate a specific individualize care plan for the patient in need and directly aid the
problem. Effective management enables the patient to return to his/her well-being and
to lessen the suffering stage.
SCOPE AND LIMITATIONS OF THE STUDY
This study focuses and is limited only to Severe Dengue. It is composed of

concepts related to the disease such as patient‘s profile and health history, nursing
assessment and clinical manifestations, drug study and diagnostic exams done. The
anatomy and physiology is included since it implicates to the pathophysiology and
associated factors of the disease. The Medical and Nursing management as well as
the discharge plans and other relevant data are also being stated.
Obtaining of information from the client and Significant others of the client was
done for three days of assessment and one day of clinical duty performed from
December 12, 2019 to December 14, 2017. Nursing Management was done on
December 13, 2019 in which the student nurse only provided the primary intervention
given in the Pediatric – Dengue Ward Department.
The areas of concerns are limited to the discussions of Dengue Severe and the quality of
Nursing Care to the patient. The quantity and quality of the information are limited to the
data gathered from the client, significant others and his medical records.
SIGNIFICANCE OF THE STUDY
Nursing Education
This study will serve as a guide towards nursing education for the students as a
reference guide for future studies regarding the disease Dengue Severe. This case study will
enable the students to learn how to assess patients with any signs Dengue Severe and
be able to provide appropriate nursing care and management.
Student will learn about the nursing interventions and have an idea of the rationale
behind the procedures. They can apply these interventions in the real setting when they
encounter a patient of the same condition. In this way, they are able to acquire more
knowledge about the disease that they can develop their skills as student nurses and
future nurses.
Nursing Practice
This study will be used as a tool in nursing practice because it provides
appropriate nursing interventions for patients with Dengue Severe. This study can give
an insight and help further in make a case study to its utmost level by making both
aspiring nurses and professional nurses prioritize giving care to patient with this
condition. And through art of practice, it is possible to develop the proper way of
handling the disease that would result to promoting health.
Nursing Research
This study can be used as a reference for further research of the current
management of patients with Dengue Severe. There might be some information within
this study that may be of relevant use to the future researchers. It is important doing
research in order to gain new information, better interventions and techniques to
provide to the patients. Aside from being a baseline date, this study may stand as a
guide for educating people about Dengue Severe, and how this put life at risk. And
through discovering and rediscovering, and trial after trial of innovative interventions
and facilitation of this condition, a more advanced using management may be
developed.
THEORETICAL FRAMEWORK
CASEY’S MODEL OF NURSING
Pediatric nursing provides resources for infants, toddlers, children, and their
families to promote health throughout development and growth. Due to the amount a
patient changes during his or her childhood, specialized care targeted to specific
development points is often necessary to meet the patient’s specific needs.
Anne Casey is an English nurse who developed a nursing theory known as

Casey’s Model of Nursing. The model was developed in 1988 while she was working in
pediatric oncology at the Great Ormond Street Hospital in London.
Casey’s Model of Nursing focuses on the nurse working in partnership with the
child and his or her family. It was one of the earliest attempts to develop a nursing
model designed specifically for child health nursing.
The five aspects of this nursing theory are child, family, health, environment, and the
nurse.
The philosophy of Casey’s model is that the best people to care for the child are
the members of the family, with health care professionals assisting. This necessitates a
relationship between the parent(s) and nurse. This model has been accepted and
adopted widely in children's units throughout the UK. However, the model has not
undergone rigorous testing to determine its contribution to nursing theory, although other
authors have since defined the concept of partnership in both scholarly and measurable
ways.
Pediatric nurses work in pediatrician’s clinics as well as hospitals and specialized

facilities focusing on the care of infants and children. In addition to being able to have the
medical knowledge and skills necessary for the job, pediatric nurses must be adept at
working with children, as well as their parents and families.
Neonatal nursing falls under the umbrella of pediatric nursing, but also comes with
its own set of skills and knowledge that lead it to be a separate specialty.
NEUMAN’S SYSTEMS MODEL
Betty Neuman’s Systems Model provides a comprehensive holistic and system-

based approach to nursing that contains an element of flexibility. The theory focuses on
the response of the patient system to actual or potential environmental stressors and the
use of primary, secondary, and tertiary nursing prevention intervention for retention,
attainment, and maintenance of patient system wellness.
The basic assumptions of the model are:
 Many known, unknown, and universal stressors exist. Each differ in their potential for
upsetting a client’s usual stability level.
 Each patient has evolved a normal range of responses to the environment referred to
as the normal line of defense. It can be used as a standard by which to measure health
deviation.
 When the flexible line of defense is incapable of protecting the patient against an
environmental stressor, that stressor breaks through the line of defense.
 Primary prevention is applied in patient assessment and intervention, in identification

and reduction of possible or actual risk factors.
 Secondary prevention relates to symptomatology following a reaction to stressors,

appropriate ranking of intervention priorities, and treatment to reduce their noxious
effects.
 Tertiary prevention relates to adjustive processes taking place as reconstitution

begins, and maintenance factors move them back in a cycle toward primary
prevention.
 The patient is in dynamic, constant energy exchange with the environment.
The major concepts of Neuman’s theory are content, which is the variables of the
person in interaction with the environment; basic structure or central core; degree to
reaction; entropy, which is a process of energy depletion and disorganization moving the
client toward illness; flexible line of defense; normal line of defense; line of resistance;
input-output; negentropy, which is a process of energy conservation that increases
organization and complexity, moving the system toward stability or a higher degree of
wellness; open system; prevention as intervention; reconstitution; stability; stressors;
wellness/illness; and prevention.
In the Systems Model, prevention is the primary intervention. It focuses on keeping
stressors and the stress response from having a detrimental effect on the body. Primary
prevention occurs before the patient reacts to a stressor. It includes health promotion and
maintaining wellness. Secondary prevention occurs after the patient reacts to a stressor
and is provided in terms of the existing system. It focuses on preventing damage to the
central core by strengthening the internal lines of resistance and removing the stressor.
Tertiary prevention occurs after the patient has been treated through secondary
prevention strategies. It offers support to the patient and tries to add energy to the patient
or reduce energy needed to facilitate reconstitution.
The Systems Model of health is equated with wellness, and defined as “the
condition in which all parts and subparts, or variables, are in harmony with the whole of
the client.” The client system moves toward illness and death when more energy is
needed than what’s available. The client system moves toward wellness when more
energy is available than is needed.
Neuman views nursing as a unique profession concerned with the variables that
influence the response the patient might have to a stressor. Nursing also addresses the
whole person, giving the theory a holistic perspective. The model defines nursing as
“actions which assists individuals, families and groups to maintain a maximum level of
wellness, and the primary aim is stability of the patient-client system, through nursing
interventions to reduce stressors.” Neuman also says the nurse’s perception must be
assessed in addition to the patient’s, since the nurse’s perception will influence the care
plan he or she sets up for the patient. The Systems Model views the role of nursing in
terms of the degree of reaction to stressors, as well as the use of primary, secondary,
and tertiary interventions.
OBJECTIVES OF THE STUDY
General Objectives:
The main objective of this case is to be able to evaluate and have a firm
background on the health condition of the patient, disease condition and their health
needs associated with Dengue Severe to achieve proper planning, management and
intervention given to meet the client’s basic demands and to prevent further
complications.
This study aims to impart knowledge, restore or maintain patient’s health status,
utilizing a holistic approach of promoting rehabilitative processes of nursing
managements. Hence, allowing the student nurses to apply their learning appropriately
in clinical setting and develop positive attitude in caring for patients with the same
condition.
Specific Objectives:
The student nurse aims to:
1. Accurately present a thorough general assessment of the client which introduces

physical assessment and family history taking.
2. Determine the causes, predisposing and precipitating factors that constitute the
onset of the disease process.
3. Effectively identify signs and symptoms exhibited by a patient with Dengue Severe.
4. Enhance the ability to manage complications brought on by Dengue Severe.
5. Thoroughly discuss, explain and elaborate the nature of the disease process.
6. Prioritize things that are essential in assessing and developing proper interventions
in managing the condition.
7. Efficiently provide appropriate and proper nursing diagnosis in line with the client’s
medical condition and skillfully formulate nursing care plans for the problems
identified.
8. Improve the use of the nursing process that would include assessment, diagnosis,
planning, implementation and evaluation into a more useful and more effective in
doing the patient’s care.
9. Provide and disseminate important information as teachings to the client and the
significant others to boost the knowing and understanding of the nature of the said
health condition.
10. Improve skills and knowledge as health care providers in the clinical area.
PATIENT'S PROFILE
Nursing Health History
The following nursing health history includes the patient's health history regarding
her condition. The researcher deemed it important to include assessing factors which may
have contributed to the patient's current health condition.
Biographical Data
Child X, is a 6-year- old girl, weigh 19 kg and stand tall at 111 cm. Child X was
born on August 06, 2013 in a Normal Spontaneous Vaginal Delivery (NSVD). She was
brought to the hospital last December 8, 2019 at 11:44 AM brought by Ambulance,
referred from Misamis Oriental provincial hospital - Balingasag and admitted to the Pedia
– Dengue Ward. They lived at Poblacion Sugbongcogon Mis. Or. Their religion is
Catholic.
Since the patient is still a child, all the information is given by the mother being the
significant other.
Vital Signs
The initial assessment was done last December 12, 2019. The vital signs were as
follows:
Day Vital Signs
PR RR Temperature Blood Oxygen

Pressure Saturation
1st day of 7 25 38.8 degrees 98%

Assessment bpm cycles/minute Celsius
(December 12,
2019)
2nd day of 89 24 36.3 degrees 90/60 98%

Assessment bpm cycles/minute Celsius mmHg
(December 2,
2019)
3rd day of 92 24 36.1 degrees 90/50 98%
(December 3,
2019
Chief Complaint
Child X was brought to Northern Mindanao Medical Center last December 8, 2019
due to hypotension.
History of Present Illness
Child X, at age of 3 years old. 4 days prior to admission, patient
Patient Health History
Child X had a previous admission and hospitalization at Gingoog Hospital last

2017 due to Acute Gastroenteritis.
Maternal and Paternal Health History
The patient has a family history of gallstone and GERD.
Patient’s General Appearance
Child X was seen to be pale, weak and skinny, and noted to have cold and clammy
skin upon assessment last December 1, 2019.
Functional Health Pattern
Upon initial assessment, the child appeared to be weak and pale. Skin is moist,
clammy and cool to touch. No lesions noted. Her vital signs were: Temperature – 38.8
degrees Celsius; Respiratory Rate – 25 cycles per minute; Heart rate – 116 beats per
minute and Blood Pressure – 90/60 mmHg. Patient X was infused of Intravenous Drip via
Infusion Pump of Dopamine at 4cc/hr and Furosemide at 8cc/hr in her left hand.
Done during initial assessment: (December 1, 2019)
Nutritional and Metabolic Pattern
The child was ordered a diet that is appropriate in her age and strict aspiration
precaution with exemption of dark colored foods such as chocolates or any chocolate
drinks. It is to let the child eat healthy foods that is appropriate for her age with strict
precaution and exemption of dark colored foods and while the child eats, she needs to be
watched and checked in order to prevent aspiration to be likely happen.
Upon assessment, the child weighed 19 kilograms and her length from head to
heel is 111 cm.
Before hospitalization, Child X usual food intake was full share of food and a bottle
of milk, approximately 4-5 times each day with good appetite and would eat four times a
day following the typical schedule of breakfast, lunch, dinner and snack.
During hospitalization, Child X was poorly nourished, fed by the mother and can
only consume half share of her food with fair appetite.
Upon initial assessment, the child weighed 19 kg and his height is 111 cm.
Elimination Pattern
Before hospitalization, Child X usually defecates one times a day or defecates

every other day with brownish color of stool and with no discomfort felt. She voids 5-6
times a day in a yellowish in color and no discomfort felt.
During hospitalization, Child X didn’t defecate for 4 days already including my shift.
Child X voids 4-5 times in yellowish in color with no discomfort felt. Child X has abnormal
perspirations since she has a cold and clammy skin.
Activity-Exercise Pattern
Child X is a very playful and active prior to the onset of disease. Child X used to
play with her toys and family especially in her sibling. Child X smiles a lot, her
coordination, gait and balance is already stable. Her daily activities were provided by her
parents somehow but she can do it independently in some way. There is no
musculoskeletal impairment.
Done during initial assessment (December 1, 2019)
PATIENTS
ACTIVITIES OF DAILY LIVING FUNCTIONAL SCORE

ABILITIES
Feeding Assist with person 2
Bathing Assist with person 2
Dressing Assist with person 2
Grooming Assist with person 2
Meal Preparation Total Dependence 4
Cleaning Total Dependence 4
Toileting Assist with person 2
Bed Mobility Independent 0
Chair/Toilet Transfer Assist with person 2
General Mobility Independent 0
ROM Independent 0
0- Total independence, 1- Assist with device, 2- assist with person, 3- assist with
device and person, 4- total dependence
Sleep-Rest Pattern
Child X usually takes naps during afternoon. At night time, she will sleep around
8pm and usually wakes up by 6am. Child X usually sleeps for 10hour. She has no history
of undisturbed sleep.
During hospitalization, Child X can only sleep for 5 hours due to the condition of
herself and the environment itself. Also, it disturbs her sleep whenever the nurse will get
a blood sample for her CBC laboratory.
Cognitive- Perceptual Pattern
The child was conscious, oriented and somewhat afraid but she still manage to
talk and can communicate well and responds well. Child X has no sensory deficits and
responds well to verbal stimulus when being called and being talked
Role-Relationship Pattern
The mother is the primary care provider of the child while the father takes care for
their financial needs and her other sibling. They have no problem raising their children.
The family has a good relationship with him and they are very helpful especially in this
time of hospitalization of the patient.
Sexuality-Reproductive Pattern
Child X has no sexuality or reproductive problem.
Value-Belief Pattern
The family’s religion is Seventh Day Adventist. The mother stated that religion is
important for them all the times, because even if they are not that wealthy enough but all
they can do is to pray and seek guidance of the Lord.
PHYSICAL ASSESSMENT
Nursing Health History
The following nursing health history includes the patient's health history regarding
her condition. The researchers deemed it important to include assessing factors which
may have contributed to the patient's current health condition.
Statement of General Appearance:
Date of Assessment: December 1, 2019
During assessment, the child is sleeping on the bed, appears to be weak, pallor,
skinny and have cold and clammy skin and febrile. She has an ongoing Intravenous Drip
via Infusion Pump of Dopamine at 4cc/hr and Furosemide at 8cc/hr in her left hand.
Date of Assessments: December 1, 2019 – December 3, 2019
Location of Assessment: Northern Mindanao Medical Center – Pedia Dengue Ward
General Health Survey
The child’s head is at its normocephalic, her length from head to heel is 111 cm
and the child weighs 19 kgs.
VITAL SIGNS
The initial assessment was done last December 1, 2019. The vital signs were as
follows:
Day Vital Signs
PR RR Temperature Blood Oxygen

Pressure Saturation
1st day of 116 25 38.8 degrees 90/60 98%
(December 1,
2019)
2nd day of 89 24 36.3 degrees 90/60 98%

(December 2,
2019)
3rd day of 92 24 36.1 degrees 90/50 98%

(December 3,
2019
 Integumentary System
Day 1 of Assessment (December 1, 2019)
Child X‘s skin was moist, cold and clammy to touch. Temperature measured
38.8 degrees Celsius taken via axilla was noted, febrile. No cyanosis was noted. No
lesions noted. The nails are clean and there is no indication of inflammation of allergies.
The texture of her skin is smooth and she has a supple turgor. Her general color was
pale.
Day 2 and 3 of Assessment (December 2 - 3, 2019)
Her extremities were warm to touch, with temperature of 36.3 and 36.1 degree
Celsius taken via axilla. Her general color was pinkish and her skin was smooth and skin
turgor is supple, and it is dry and smooth. No lesions noted. The nails are clean and there
is no indication of inflammation of allergies.
 Head, Eyes, Ears, Nose and Throat (HEENT)
Days 1 of Assessment (December 1, 2019)
Head was normocephalic, with symmetrical facial movements. Hair was fine in
distribution with no dandruff nor wounds and scars. Eyelids were symmetrical in
alignment with no redness, lesions and swelling. There is a sunken eyeballs in the
periorbital. Conjunctiva was pale in color with no lesions and discharges, with anicteric
sclera. Pupils were equal in size in 3mm, round and brisk reaction to light with uniform in
constriction and grossly normal in visual acuity with intact/full gaze on eyes as peripheral
vision. External pinnae were symmetrical in alignment, with no tenderness and lesions.
No discharges noted. Gross hearing was normal. Septum of nose was in midline. With
no discharges observed. Smell was normal and symmetrical. No tenderness in sinuses.
Pallor and cracked of lips were noted. Pinkish mucosa was noted; tongue was in midline,
with missing teeth due to carries and pale gums. Uvula was in midline. Tonsils not
inflamed. The skin was pallor, but it is smooth and supple. And his temperature was
warm.
Days 2 and 3 of Assessment (December 2 - 3, 2019)
Head was normocephalic, with symmetrical facial movements. Hair was fine in
distribution with no dandruff nor wounds and scars. Eyelids were symmetrical in
alignment with no redness, lesions and swelling. There is still a sunken eyeball in the
periorbital. Conjunctiva was pinkish in color with no lesions and discharges, with anicteric
sclera. Pupils were equal in size in 3mm, round and brisk reaction to light with uniform in
constriction and grossly normal in visual acuity with intact/full gaze on eyes as peripheral
vision. External pinnae were symmetrical in alignment, with no tenderness and lesions.
No discharges noted. Gross hearing was normal. Septum of nose was in midline. With
no discharges observed. Smell was normal and symmetrical. No tenderness in sinuses.
Slightly pinkish lips are seen in the patient. Pinkish mucosa was noted; tongue was in
midline, with missing teeth due to carries and pinkish gums. Uvula was in midline. Tonsils
not inflamed. The skin was slightly pinkish, but it is smooth and supple. And her
temperature was warm and dry to touch.
 RESPIRATORY SYSTEM
There was a regular breathing pattern of the patient during the assessments.
Day 1 – 3 of Assessment (December 1 - 3, 2019)
Trachea was in midline upon palpation. Breathing pattern was regular, with
symmetrical lung expansion. Upon inspection, respiratory rate was 25 cycles per minute
during the first day of assessment (December 1, 2019) and respiratory rate was 24 cycles
per minute during the second day of assessment (December 2, 2019) and respiratory
rate was 24 cycles per minute during the third day of assessment (December 3, 2019)
with normal inspiration and expiration.
 BREAST AND LYMPHATIC SYSTEM

Days 1 – 3 of Assessment (December 1 - 3, 2019)
Breasts were of equal size with no masses or tenderness. The surface was
smooth with no retraction or dimpling. No tenderness of lymph nodes.
 CARDIOVASCULAR SYSTEM
Heart rate was regular with pulse rate of 116 beats per minute. Blood pressure
was measured 90/60 mmHg. Capillary refill was assessed < 2 seconds and pinkish
nailbeds.
Heart rate was regular with pulse rate of 89 beats per minute. Blood pressure was
90/60 mmHg. Capillary refill was assessed < 2 seconds and pinkish nailbeds.
Heart rate was regular with pulse rate of 92 beats per minute. Blood pressure was
90/50 mmHg. Capillary refill was assessed < 2 seconds and pinkish nailbeds.
 GASTROINTESTINAL SYSTEM
The abdomen of the child is not distended and it has superficial veins in
appearance of it. The configuration of it is symmetrical and the percussion of it is
tympanitic so it is in normal range. Her abdomen is in muscle guarding. She has a
normoactive bowel sounds.
 GENITOURINARY SYSTEM
The child’s urinary meatus is midline and voided regularly with a 300 – 350 cc per
void of yellowish urine. External genitalia have no lesions noted and it is symmetrical.
 MUSCOLOSKELETAL SYSTEM

Child X had normal range of motion. She has a complete set of fingers and toes.
No dimpling is observed. There are equal gluteal folds. No joint tenderness and varicose
veins observed. Muscle tone and strength symmetrical in size and equally strong. Spine
was midline and gait was coordinated. Arms and legs are symmetrical in size and
movement.
 NEUROLOGICAL SYSTEM
Day 1 – 3 of Assessment (December 1 - 3, 2019))
Child X was conscious but appears weak, tired and lethargy. However, she was
oriented and responds well to conversations. The child’s cerebral function is still working
on its mental functions. She is able to speech or speaks, do problem solving, and can
still remember. Her speech was clear. The language she uses is appropriate for the
education and socioeconomics levels of the person. The child’s neurological system is
well functioning.
Day 1 of Assessment: December 1, 2019
HEENT:skull symmetrical, Neurological: The patient

normocephalic closed is able to speak, do problem
anterior fontanel, posterior solving, and can still
fontanel closed, sunken remember. Her speech was
eyes, positive red light clearly spoken at an
reflex (OU), reacts to appropriate rate. The
noise, nares patent, and patient’s neurological
palate intact, Pale system is well functioning.
conjunctiva, hair is fine Oriented, calm and
responsive
Respiratory: RR Cardiovascular: HR 116

25cpm, regular bpm, no cyanosis noted
inspiration
Gastrointestinal:
Integumentary: Abdomen not distended
Temp-38.8⁰C, moist with normoactive bowel
and clammy moisture. sounds, didn’t defecate in
Skin is warm to touch a day.
but it is moist. Skin
color is pale, febrile.
Musculoskeletal: Good
Genitourinary: muscle tone, equal gluteal
Urinary meatus is folds, symmetrical
midline and movements, no fractures and
uninterrupted stream clicks on joint, full range of
is noted on voiding, motion on extremities,
no nodules and complete fingers and toes, no
discharges injuries noted
Day 2 of Assessment: December 2, 2019
Neurological: The patient

is able to speak, do problem
HEENT: skull symmetrical, solving, and can still
normocephalic closed remember. Her speech was
anterior fontanel, posterior clearly spoken at an
fontanel closed, sunken eyes, appropriate rate. The
positive red light reflex (OU), patient’s neurological
reacts to noise, nares patent, system is well functioning.
and palate intact, Pinkish Oriented, calm and
conjunctiva, hair is fine responsive
Respiratory: Cardiovascular: HR
89 bpm, no cyanosis
RR 24 cpm,
noted
regular, with
normal
inspiration
Gastrointestinal:
Integumentary:
Temp-36.3⁰C, skin is Abdomen not distended
warm to touch and dry. with normoactive bowel
Skin color is not pale, sounds, didn’t defecate in
afebrile. a day.
Musculoskeletal: Good
Genitourinary:
muscle tone, equal gluteal
Urinary meatus is
folds,symmetrical movements,
midline and
no fractures and clicks on joint,
uninterrupted stream
full range of motion on
is noted on voiding,
extremities, complete fingers
no nodules and
and toes, no injuries noted
discharges
Day 3 of Assessment: August 24, 2019
Neurological: The patient

HEENT: skull symmetrical, is able to speak, do problem
normocephalic closed solving, and can still
anterior fontanel, posterior remember. Her speech was
fontanel closed, sunken eyes, clearly spoken at an
positive red light reflex (OU), appropriate rate. The
reacts to noise, nares patent, patient’s neurological
and palate intact, Pinkish system is well functioning.
conjunctiva, hair is fine Oriented, calm and
responsive
Respiratory: RR
24cpm, regular, Cardiovascular: HR
with normal 92 bpm, no cyanosis
inspiration noted
Gastrointestinal:
Integumentary:
Temp-36.1⁰C, skin is Abdomen not distended
warm to touch and dry. with normoactive bowel
Skin color is not pale, sounds, did defecate once
afebrile. in a day with brownish
formed stool
Musculoskeletal:
Genitourinary:
Urinary meatus is Good muscle tone, equal
midline and gluteal folds, symmetrical
uninterrupted stream movements, no fractures and
is noted on voiding, clicks on joint, full range of
no nodules and motion on extremities,
discharges complete fingers and toes, no
injuries noted
DEVELOPMENTAL DATA
A. Psychosocial Theory by Erik Erikson
Erik Erikson maintained that personality develops in a predetermined order

through eight stages of psychosocial development, from infancy to adulthood. During each
stage, the person experiences a psychosocial crisis which could have a positive or
negative outcome for personality development.
Autonomy vs. Shame (School Age 1 ½ - 3)
Autonomy versus shame and doubt is the second stage of Erik Erikson's stages of
psychosocial development. This stage occurs between the ages of 18 months to
approximately 3 years. According to Erikson, children at this stage are focused on
developing a sense of personal control over physical skills and a sense of independence.
Success in this stage will lead to the virtue of will. If children in this stage are
encouraged and supported in their increased independence, they become more confident
and secure in their own ability to survive in the world. If children are criticized, overly
controlled, or not given the opportunity to assert themselves, they begin to feel inadequate
in their ability to survive, and may then become overly dependent upon others, lack self-
esteem, and feel a sense of shame or doubt in their abilities.
The child is developing physically and becoming more mobile, and discovering that
he or she has many skills and abilities, such as putting on clothes and shoes, playing with
toys, etc. Such skills illustrate the child's growing sense of independence and autonomy.
Initiative vs. Guilt (Toddler Age 3 – 5)
Initiative versus guilt is the third stage of Erik Erikson's theory of psychosocial
development. During the initiative versus guilt stage, children assert themselves more
frequently. These are particularly lively, rapid-developing years in a child’s life. According
to Bee (1992), it is a “time of vigor of action and of behaviors that the parents may see as
aggressive."
During this period the primary feature involves the child regularly interacting with
other children at school. Central to this stage is play, as it provides children with the
opportunity to explore their interpersonal skills through initiating activities. Children begin
to plan activities, make up games, and initiate activities with others. If given this
opportunity, children develop a sense of initiative and feel secure in their ability to lead
others and make decisions.
Too much guilt can make the child slow to interact with others and may inhibit their
creativity. Some guilt is, of course, necessary; otherwise the child would not know how to
exercise self-control or have a conscience. A healthy balance between initiative and guilt
is important. Success in this stage will lead to the virtue of purpose, while failure results
in a sense of guilt.
B. Psychosexual Theory by Sigmund Freud
Sigmund Freud meant to convey that what develops is the way in which sexual
energy accumulates and is discharged as we mature biologically. A predetermined
sequence and can result in either successful completion or a healthy personality or can
result in failure, leading to an unhealthy personality.
Anal Stage (2 – 3 years old)
The main source of gratification at this stage is the ability to control bladder
movement and the elimination or retention of feces. A positive and appropriate experience
revolving around potty training can encourage competence, creativity and productivity in
individuals. Contrarily, anal fixations can translate into obsession with perfection, extreme
cleanliness, and control or the opposite which is messiness and disorganization in
adulthood.
Phallic Stage (3 – 6 years old)
At this Freud psychosexual stage, the focus of pleasure is the genitals. Boys start
to perceive their father as rivals for their mother’s affections, while girls feel similarly
towards their mother. Fear of punishment can lead to repression of feelings felt toward
the opposite sex parent. Fixation at this stage may bring about sexual deviancy or weak
sexual identity.
One importance of this psychosexual theory is the emphasis on early experiences in the
development of personality and as an influence on later behavior. The relationship that
children cultivate, the views about themselves and others, and their level of adjustment
and well-being as adults are all influenced by the quality of experiences that they have
had in each psychosexual stage.
CONCEPTUAL THEORY
Betty Neuman
Betty Neuman’s conceptual theory is a holistic approach that encourages focus to

health promotion, maintenance of wellness, prevention and management of stressors that
are perceived as leading to ill health. The nursing goal is to retain the patient’s system
stability through three levels of prevention:
1. Primary prevention: to protect and strengthen the flexible line of defense

2. Secondary prevention: to help restore the client system to equilibrium by
treating symptoms that occur after penetration of the line of defense by a
stressor
3. Tertiary prevention: to prevent further damage and maintain stability after
reconstitution has occurred
Through this model, practioners are encouraged to see the patient as a whole—that
people are open systems that interact with its internal and external environments to
maintain balance.
The Neuman systems model is based on a general system theory and reflects the
nature of living organisms as open systems in interaction with each other and with the
environment. Within the Neuman model, the client may be an individual, a family, a group,
a community, or a social entity. An important assumption of the Newman theory is: “each
client system is unique, a composite of factors and characteristics within a given range of
responses.
The human being is a total person, characterized by five variables: these include
physiological, psychological, socio-cultural, spiritual, and developmental variables. The
physiological variable refers to body structure and function. The psychological variable
refers to mental processes in interaction with the environment. The socio-cultural variable
refers to the effects and influences of social and cultural conditions. The spiritual variable
refers to spiritual beliefs and influences. The developmental variable refers to age-related
processes and activities.
An individual organism is said to have a central “core” of basic survival

mechanisms, such as temperature control, ego, and organ function. The core is protected
by lines of defense. The outer layer is the flexible line of defense, and is variable,
responding to the particular stressor. The inner or “normal” line of defense represents the
state of wellness and adaptation of the individual. It is generally stable.
Neuman believes that nursing is concerned with the whole person. She views
nursing as a unique profession and believes that it is concerned with all the variables
affecting an individual’s response to stress. The primary aim of nursing is the stability of
the client system. This is achieved through nursing intervention to reduce the stressors.
Neuman’s process contains three basic parts: nursing diagnosis, nursing goals, and
nursing outcomes. Neuman stresses the importance of identifying the client’s and the
caregiver’s perceptions and collaboration between the client and the caregiver in all
stages of the process.
ANATOMY AND PHYSIOLOGY
CIRCULATORY SYSTEM
The circulatory system, also called the cardiovascular system or the vascular
system, is an organ system that permits blood to circulate and transport nutrients (such
as amino acids and electrolytes), oxygen, carbon dioxide, hormones, and blood cells to
and from the cells in the body to provide nourishment and help in fighting
diseases, stabilize temperature and pH, and maintain homeostasis.
The circulatory system includes the lymphatic system, which circulates lymph. The
passage of lymph takes much longer than that of blood. Blood is a fluid consisting
of plasma, red blood cells, white blood cells, and platelets that is circulated by
the heart through the vertebrate vascular system, carrying oxygen and nutrients to and
waste materials away from all body tissues. Lymph is essentially recycled excess blood
plasma after it has been filtered from the interstitial fluid (between cells) and returned to
the lymphatic system. The cardiovascular (from Latin words meaning "heart" and
"vessel") system comprises the blood, heart, and blood vessels. The lymph, lymph nodes,
and lymph vessels form the lymphatic system, which returns filtered blood plasma from
the interstitial fluid (between cells) as lymph.
The circulatory system of the blood is seen as having two components, a systemic
circulation and a pulmonary circulation. While humans, as well as other vertebrates, have
a closed cardiovascular system (meaning that the blood never leaves the network
of arteries, veins and capillaries), some invertebrate groups have an open cardiovascular
system. The lymphatic system, on the other hand, is an open system providing an
accessory route for excess interstitial fluid to be returned to the blood. The more
primitive, diploblastic animal phyla lack circulatory systems.
Many diseases affect the circulatory system. This includes cardiovascular disease,
affecting the cardiovascular system, and lymphatic disease affecting the lymphatic
system. Cardiologists are medical professionals which specialise in the heart,
and cardiothoracic surgeons specialise in operating on the heart and its surrounding
areas. Vascular surgeons focus on other parts of the circulatory system.
The essential components of the human cardiovascular system are

the heart, blood and blood vessels. It includes the pulmonary circulation, a "loop" through
the lungs where blood is oxygenated; and the systemic circulation, a "loop" through the
rest of the body to provide oxygenated blood. The systemic circulation can also be seen
to function in two parts – a macrocirculation and a microcirculation. An average adult
contains five to six quarts (roughly 4.7 to 5.7 liters) of blood, accounting for approximately
7% of their total body weight. Blood consists of plasma, red blood cells, white blood cells,
and platelets. Also, the digestive system works with the circulatory system to provide the
nutrients the system needs to keep the heart pumping.
The cardiovascular systems of humans are closed, meaning that the blood never
leaves the network of blood vessels. In contrast, oxygen and nutrients diffuse across the
blood vessel layers and enter interstitial fluid, which carries oxygen and nutrients to the
target cells, and carbon dioxide and wastes in the opposite direction. The other
component of the circulatory system, the lymphatic system, is open.
THE HEART
The heart pumps oxygenated blood to the body and deoxygenated blood to the
lungs. In the human heart there is one atrium and one ventricle for each circulation, and
with both a systemic and a pulmonary circulation there are four chambers in total: left
atrium, left ventricle, right atrium and right ventricle. The right atrium is the upper chamber
of the right side of the heart. The blood that is returned to the right atrium is deoxygenated
(poor in oxygen) and passed into the right ventricle to be pumped through the pulmonary
artery to the lungs for re-oxygenation and removal of carbon dioxide. The left atrium
receives newly oxygenated blood from the lungs as well as the pulmonary vein which is
passed into the strong left ventricle to be pumped through the aorta to the different organs
of the body.
The heart is made of specialized cardiac muscle tissue that allows it to act as a
pump within the circulatory system. The human heart is divided into four chambers. There
are one atrium and one ventricle on each side of the heart. The atria receive blood and
the ventricles pump blood.
The human circulatory system consists of several circuits:
 The pulmonary circuit provides blood flow between the heart and lungs.
 The systemic circuit allows blood to flow to and from the rest of the body.
 The coronary circuit strictly provides blood to the heart
BLOOD AND BLOOD VESSELS
Blood from the heart is pumped throughout the body using blood vessels. Arteries
carry blood away from the heart and into capillaries, providing oxygen (and other
nutrients) to tissue and cells. Once oxygen is removed, the blood travels back to the lungs,
where it is reoxygenated and returned by veins to the heart.
Arteries
Oxygenated blood enters the systemic circulation when leaving the left ventricle,
through the aortic semilunar valve. The first part of the systemic circulation is the aorta, a
massive and thick-walled artery. The aorta arches and gives branches supplying the
upper part of the body after passing through the aortic opening of the diaphragm at the
level of thoracic ten vertebra, it enters the abdomen. Later it descends down and supplies
branches to abdomen, pelvis, perineum and the lower limbs. The walls of aorta are elastic.
This elasticity helps to maintain the blood pressure throughout the body. When the aorta
receives almost five litres of blood from the heart, it recoils and is responsible for pulsating
blood pressure. Moreover, as aorta branches into smaller arteries, their elasticity goes on
decreasing and their compliance goes on increasing.
Capillaries
Arteries branch into small passages called arterioles and then into
the capillaries. The capillaries merge to bring blood into the venous system.
Veins
Capillaries merge into venules, which merge into veins. The venous system feeds
into the two major veins: the superior vena cava – which mainly drains tissues above the
heart – and the inferior vena cava – which mainly drains tissues below the heart. These
two large veins empty into the right atrium of the heart.
Portal veins
The general rule is that arteries from the heart branch out into capillaries, which
collect into veins leading back to the heart. Portal veins are a slight exception to this. In
humans the only significant example is the hepatic portal vein which combines from
capillaries around the gastrointestinal tract where the blood absorbs the various products
of digestion; rather than leading directly back to the heart, the hepatic portal vein branches
into a second capillary system in the liver.
Coronary vessels
The heart itself is supplied with oxygen and nutrients through a small "loop" of the
systemic circulation and derives very little from the blood contained within the four
chambers. The coronary circulation system provides a blood supply to the heart
muscle itself. The coronary circulation begins near the origin of the aorta by two coronary
arteries: the right coronary artery and the left coronary artery. After nourishing the heart
muscle, blood returns through the coronary veins into the coronary sinus and from this
one into the right atrium. Back flow of blood through its opening during atrial systole is
prevented by Thebesian valve. The smallest cardiac veins drain directly into the heart
chambers.
SYSTEMIC CIRCULATION
Systemic circulation is the portion of the cardiovascular system which transports
oxygenated blood away from the heart through the aorta from the left ventricle where the
blood has been previously deposited from pulmonary circulation, to the rest of the body,
and returns oxygen-depleted blood back to the heart.
Blood is a body fluid in humans and other animals that delivers necessary
substances such as nutrients and oxygen to the cells and transports metabolic
waste products away from those same cells.
Blood is circulated around the body through blood vessels by the pumping action
of the heart. In animals with lungs, arterial blood carries oxygen from inhaled air to the
tissues of the body, and venous blood carries carbon dioxide, a waste product
of metabolism produced by cells, from the tissues to the lungs to be exhaled.
Medical terms related to blood often begin with hemo- or hemato- (also
spelled haemo- and haemato-) from the Greek word αἷμα (haima) for "blood". In terms
of anatomy and histology, blood is considered a specialized form of connective tissue,
given its origin in the bones and the presence of potential molecular fibers in the form
of fibrinogen.
Blood Components
There are four basic components that comprise human blood: plasma, red blood cells,
white blood cells and platelets.
Red Blood Cells
Red blood cells represent 40%-45% of your blood volume. They are generated
from your bone marrow at a rate of four to five billion per hour. They have a lifecycle of
about 120 days in the body.
Platelets
Platelets are an amazing part of your blood. Platelets are the smallest of our blood
cells and literally look like small plates in their non-active form. Platelets control bleeding.
Wherever a wound occurs, the blood vessel will send out a signal. Platelets receive that
signal and travel to the area and transform into their “active” formation, growing long
tentacles to make contact with the vessel and form clusters to plug the wound until it
heals.
Plasma
Plasma is the liquid portion of your blood. Plasma is yellowish in color and is made
up mostly of water, but it also contains proteins, sugars, hormones and salts. It transports
water and nutrients to your body’s tissues.
White Blood Cells
Although white blood cells (leukocytes) only account for about 1% of your blood,
they are very important. White blood cells are essential for good health and protection
against illness and disease. Like red blood cells, they are constantly being generated
from your bone marrow. They flow through the bloodstream and attack foreign bodies,
like viruses and bacteria. They can even leave the bloodstream to extend the fight into
tissue.
PATHOPHYSIOLOGY
DENGUE SEVERE
PREDISPOSING FACTORS:
PRECIPITATING FACTORS:
 Age  Environment
 Race-Ethnicity
SECOND DENGUE INFECTION
ANTIBODY FORMATION
REINFECTION
AUGMENTATION OF VIRUS MULTIPLICATION
INCREASED VASCULAR PERMEABILITY DECREASED PLATELET COUNT
LEAKAGE OF THE PLASMA HEMORRHAGIC MANIFESTATION
HYPOVOLEMIA COAGULOPATHY
TISSUE HYPOXIA AND SHOCK DISSEMINATED

INTRAVASCULAR
COAGULATION
LOW BLOOD PRESSURE CONSTIPATED/ FEVER VOMITING PETECHIAE

ABNORMAL
BOWEL PATERN
LEGENDARY
CONSTIPATION HYPERTHERMIA RISK FOR BLEEDING
DOPAMINE 4cc/hr OMEPRAZOLE 200mg FUROSEMIDE 8cc/hr

DseMedications
Process
NCP Signs and Symptoms
CBC LAB TEST

Labtest
DIAGNOSTIC TEST
IDEAL:
COMPLETE BLOOD COUNT
Complete blood count is monitored for any hematologic abnormalities and to

monitor presence of infections. The complete blood count or CBC test is used as a broad
screening test to check for such disorders as anemia, infection, and many other diseases.
It is actually a panel of tests that examines different parts of the blood and includes the
following:
• White blood cell (WBC) count is a count of the actual number of white blood cells
per volume of blood. Both increases and decreases can be significant.
• White blood cell differential looks at the types of white blood cells present. There
are five different types of white blood cells, each with its own function in protecting us
from infection. The differential classifies a person's white blood cells into each type:
neutrophils (also known as segs, PMNs, granulocytes, grans), lymphocytes, monocytes,
eosinophils, and basophils.
• Red blood cell (RBC) count is a count of the actual number of red blood cells per
volume of blood. Both increases and decreases can point to abnormal conditions.
• Hemoglobin measures the amount of oxygen-carrying protein in the blood.
• Hematocrit measures the percentage of red blood cells in a given volume of

whole blood.
• The platelet count is the number of platelets in a given volume of blood. Both
increases and decreases can point to abnormal conditions of excess bleeding or clotting.
Mean platelet volume (MPV) is a machine-calculated measurement of the average size
of your platelets. New platelets are larger, and an increased MPV occurs when increased
numbers of platelets are being produced. MPV gives your doctor information about
platelet production in your bone marrow.
• Mean corpuscular volume (MCV) is a measurement of the average size of your

RBCs. The MCV is elevated when your RBCs are larger than normal (macrocytic), for
example in anemia caused by vitamin B12 deficiency. When the MCV is decreased, your
RBCs are smaller than normal (microcytic) as is seen in iron deficiency anemia or
thalassemias.
• Mean corpuscular hemoglobin (MCH) is a calculation of the average amount of
oxygen-carrying hemoglobin inside a red blood cell. Macrocytic RBCs are large so tend
to have a higher MCH, while microcytic red cells would have a lower value.
• Mean corpuscular hemoglobin concentration (MCHC) is a calculation of the

average concentration of hemoglobin inside a red cell. Decreased MCHC values
(hypochromia) are seen in conditions where the hemoglobin is abnormally diluted inside
the red cells, such as in iron deficiency anemia and in thalassemia. Increased MCHC
values (hyperchromia) are seen in conditions where the hemoglobin is abnormally
concentrated inside the red cells, such as in burn patients and hereditary spherocytosis,
a relatively rare congenital disorder.
• Mean platelet volume (MPV) is a machine-calculated measurement of the

average size of platelets found in blood and is typically included in blood tests as part of
the CBC. Since the average platelet size is larger when the body is producing increased
numbers of platelets, the MPV test results can be used to make inferences about platelet
production in bone marrow or platelet destruction problems. MPV is higher when there is
destruction of platelets. This may be seen in inflammatory bowel disease, immune
thrombocytopenic purpura (ITP), myeloproliferative diseases and Bernard-Soulier
syndrome. It may also be related to pre-eclampsia and recovery from
transient hypoplasia.
• Red cell distribution width (RDW) is a calculation of the variation in the size of
your RBCs. In some anemias, such aspernicious anemia, the amount of variation
(anisocytosis) in RBC size (along with variation in shape – poikilocytosis) causes an
increase in the RDW.
URINALYSIS
Urinalysis is monitored for kidney function and monitoring for metabolic waste.
Urinalysis is the physical, chemical, and microscopic examination of urine. It involves a
number of tests to detect and measure various compounds that pass through the urine.
DIAGNOSTIC TEST
December 9, 2019 11:03 AM
PARAMETERS RESULT UNIT REFERENCE INTERPRETATION IMPLICATION
VALUE
WBC COUNT 7.51 X10^9/L 5.0-10.0 Normal Normal level

indicates normal
WBC
RBC COUNT 4.90 X10^6/L 3.50 – 5.50 Normal Normal level

indicates normal
RBC cells
Hemoglobin 13.30 g/L 12.0-18.0 Normal Normal amount

indicates normal
level of O2 in the
cell
Hematocrit 37.40 % 37.0-52.0 Normal Normal level

indicates normal
volume of blood
cells.
Platelet Count 42,000 uL 150,000- Decreased Decrease level

450,00 indicates
bleeding
RED CELL INDICES
MCV 76.30 fL 82.0 – 98.0 Decreased Decrease in

MCV indicates
that RBC are too
small.
MCH 27.10 pg 27.0 - 31.0 Normal Normal level
indicates the
RBC size.
MCHC 35.60 g/dL 31.5 - 35.0 Increased Increase level

indicates
increase
concentration of
hemoglobin
RDW-CV 12.30 % 11.60 - 17.0 Normal Normal RDW

produces cells
that are normal
PDW 11.60 fL 9.0 – 16.0 Normal Normal

Distribution
MPV 9.50 fL 8.0 – 12.0 Normal Normal size of

platelets found in
blood
DIFFERENTIAL COUNT
NEUTROPHIL 21.0 % 43.4 – 76.2 Decreased Decreased level

(%) of
neutrophil
indicates less
protection from
infection.
LYMPHOCYTE 63.30 % 17.0 – 57.0 Increased High level of

(%)
lymphocyte
responses to an
infection or
inflammatory.
MONOCYTE 10.00 % 4.5 – 10.5 Normal Normal level

(%)
EOSINOPHIL 0.30 % 1.0 – 3.0 Decreased Decreased level

(%) of eosinophils
BASOPHIL (%) 0.30 % 0.0-2.0 Normal Normal

circulating WBC
December 10, 2019 8:25 PM
VALUE
WBC COUNT 6.18 X10^9/L 5.0-10.0 Normal Normal level

indicates normal
WBC
RBC COUNT 4.87 X10^6/L 3.50 – 5.50 Normal Normal amount

of RBC per
volume of blood

indicates normal
level of O2 in the
cell
Hematocrit 36.60 % 37.0-48.0 Decreased Below-average is

an insufficient
supply of healthy
red blood cells
Platelet Count 113,000 uL 150,000- Decreased Decrease level

450,00 indicates
bleeding
RED CELL INDICES
MCV 75.20 fL 82.0 – 98.0 Decreased Decrease level

indicates small
RBC size.
MCH 26.90 pg 27.0 - 31.0 Decrease Decreased level

indicates the
smaller RBC
size.
MCHC 35.80 g/dL 31.5 - 35.0 Increased Increased level

indicates
abnormal
concentration of
hemoglobin
RDW-CV 11.70 % 12.0 - 17.0 Decreased Decreased

levels of variably
shaped and
sized red blood
cells
PDW 11.50 fL 9.0 – 16.0 Normal Platelets are in

regular
distribution

platelets found in
blood
DIFFERENTIAL COUNT

(%) of
neutrophil
indicates lower
protection from
infection.
LYMPHOCYTE 55.80 % 17.4 – 48.2 Increased Normal level of

(%)
lymphocyte
responses to an
infection or
inflammatory.
MONOCYTE 13.40 % 4.5 – 10.5 Increased Increase level of

(%)
monocyte may
indicate to
response of
presence of
chronic infection.
EOSINOPHIL 0.50 % 1.0 – 3.0 Decreased Decrease level

(%) indicates
infection

circulating WBC
December 12, 2019 1:31 PM
VALUE
WBC COUNT 6.22 X10^9/L 5.0-10.0 Normal Increased WBC

indicates
infection

of RBC per
volume of blood

indicates normal
level of O2 in the
cell

an insufficient
supply of healthy
red blood cells
Platelet Count 282,000 uL 150,000- Normal Normal

450,00
percentage of
platelet count
and coagulation.
RED CELL INDICES

indicates small
RBC size.
MCH 26.50 pg 27.0 - 31.0 Decreased Decreased level
indicates the
RBC size.
MCHC 35 g/dL 31.5 - 35.0 Normal Normal level

indicates
average
concentration of
hemoglobin
RDW-CV 11.80 % 12.0 - 17.0 Normal Normal level of

RBC in the body.

regular
distribution

platelets found in
blood
DIFFERENTIAL COUNT
NEUTROPHIL 48.00 % 43.4 – 76.2 Normal Normal level of

(%)
neutrophil
indicates
protection from
infection.
LYMPHOCYTE 38.30 % 17.4 – 48.2 Normal Normal level of

(%)
lymphocyte
responses to an
infection or
inflammatory.
MONOCYTE 12.40 % 4.5 – 10.5 Increased Increased level

(%) of monocyte may
indicate to
response of
presence of
chronic infection.
EOSINOPHIL 1.10 % 1.0 – 3.0 Normal Normal level

(%)
may indicate to
response of
presence of
infection

circulating WBC
December 13, 2019 10:21 AM
VALUE
WBC COUNT 5.73 X10^9/L 5.0-10.0 Normal Normal amount

indicates to fight
off infection

of RBC per
volume of blood

indicates normal
level of O2 in the
cell

an insufficient
supply of healthy
red blood cells
Platelet Count 420,000 uL 150,000- Normal Normal

450,00
percentage of
platelet count
and coagulation
RED CELL INDICES

indicates small
RBC size.
MCH 26.70 pg 27.0 - 31.0 Decreased Decrease level
indicates the
RBC size.
MCHC 35.50 g/dL 31.5 - 35.0 Increased Increase level

indicates
abnormal
concentration of
hemoglobin
RDW-CV 11.90 % 12.0 - 17.0 Decrease Decreased level

of RBC in the
body.

regular
distribution

platelets found in
blood
DIFFERENTIAL COUNT

(%) of
neutrophil
indicates less
protection from
infection.
LYMPHOCYTE 40.50 % 17.4 – 48.2 Normal Normal level of

(%)
lymphocyte
responses to an
infection or
inflammatory.
MONOCYTE 18.50 % 4.5 – 10.5 Increased Increase level of

(%)
monocyte may
indicate to
response of
presence of
chronic infection.
EOSINOPHIL 3.00 % 1.0 – 3.0 Increased Increased level

(%) of eosinophil
amount may be
a form of allergic
reaction.

circulating WBC
COMPLETE URINALYSIS RESULT
Novermber 27, 2019
PHYSICAL PROPERTIES
COLOR: Light Yellow CLARITY: Clear
SPECIFIC GRAV: 1.010 PH: 6.0
ODOR:
CHEMICAL PROPERTIES
PROTEINS: NEGATIVE GLUCOSE: NEGATIVE
BILIRUBIN: UROBILINOGEN:
KETONES: NITRITES:
BLOOD: LUEKOCYTES:
ESTERASE:
SEDIMENT/MICROSCOPIC EXAMINATION
EPITH. CELLS: MODERATE WHITE BLOOD CELL: 0-1/HPF
RED BLOOD CELL: 28 - 30 RENAL CELLS
TUMOR CELLS: YEASTS:
BACTERIA: FEW PUS CELLS: 4-5
CRYSTALS
CALCIUM OXALATE: URIC ACID:
AMORPH URATES TRIPLE PHOSPHATES

CASTS:
HYALINE: FINE GRANULAR:
COARSELY MUCUS THREADS: MODERATE

GRANULAR:
OTHERS:
IMMUNIZATION RECORD (Mark if Given)
BCG: 
HEPA B: 
PENTAVALENT/DPT(3): 
PCV: 
POLIO: 
ROTA VIRUS: 
MEASLES: 
MMR: 
IPV: 
VITAMIN A SUPPLEMENTATION: 
IRON SUPPLEMENTATION: 
DEWORMING: 
MEDICAL AND SURGICAL MANAGEMENT
MEDICAL MANAGEMENT:
DRUG STUDY
1.)
Drug Name: Captopril
Brand Name: Capoten
Classification: ACE Inhibitor
Dose: 3.5ml
Route: PO
Frequency: Every 12 hour
Mechanism of Action: Used to block the action of angiotensin converting enzyme which
is naturally produced in the body. ACE produces angiotensin II which causes constriction
and narrowing of the blood vessels thereby increasing blood pressure. By blocking ACE,
production of angiotensin II decreases allowing the blood vessels to relax and widen
resulting in decrease blood pressure.
Indication: Captopril is used alone or in combination of other drugs for management of

hypertension. It is also used in combination with other drugs in treatment of heart failure
after a heart attack, also used to treat kidney problems caused by diabetic nephropathy.
Contraindication: Allergy to other ACE inhibitors. Aortic stenosis, outflow obstruction,
renovascular disease, and pregnancy and Lactation. Caution in cases where patients also
have leukemia, COPD, renal or thyroid disease.
Adverse Effects:
Hypotension, dizziness, dry mouth, itching, sleep problems, rashes, diarrhea,

constipation, hair loss, dry irritating cough, changes in the way things taste, upset
stomach, abdominal pain, shortness of breath, Agranulocytosis, neutropenia
Nursing Responsibilities:
 Monitor blood pressure and pulse frequently

 Monitor weight and assesses patient frequently for signs of fluid overload if with
concurrent diuretic therapy.
 Assessments of urine protein may be ordered. Proteinuria and nephrotic
syndrome may occur with therapy.
 Monitor BUN, Crea, and electrolyte levels periodically.
 WBC should be monitored prior to therapy and periodically thereafter.
 May cause false positive result for urine acetone
2.)
Drug Name: Omeprazole
Brand Name: Losec
Classification: Gastro-intestinal agent, Anti-ulcer drugs
Dose: 20 mg
Route: IVTT
Frequency: OD (once a day)
Mechanism of Action: Inhibits activity of acid (proton) pump and binds to hydrogen-
potassium adenosine triphosphatase at secretory surface of gastric parietal cells to block
formation of gastric acid. An anti-secretory compound that is gastric acid pump inhibitor,
suppresses gastric acid secretion by inhibiting enzyme
Indication: Symptomatic gastroesophageal reflux disease (GERD) without esophageal

lesions, Erosive esophagitis and accompanying caused by GERD, Duodenal ulcer,
Helicobacter pylori infections, short-term treatment of active benign gastric ulcer
Contraindication: Contraindicated in patients with hypersensitive to drug or its

components
Adverse Effects:
CNS: Headache, Dizziness, Asthenia
GI: Diarrhea, Abdominal pain, Nausea, Vomiting, Constipation, Flatulence
MUSCULOSKELETAL: Back pain
RESPIRATORY: Cough, URTI

SKIN: Rash
Nursing Responsibilities:
1. Tell patient to swallow capsules whole and not to open, crush or chew them.
2. Instruct patient to take drug 30 minutes before meals.
3. Caution patients to avoid hazardous activities if he gets dizzy.

NURSING MANAGEMENT
NURSING CARE PLAN
Priority problem #1: Hyperthermia related to illness as evidenced by Temperature

of 38.8 degrees Celsius
Objective:
 Temperature of 38.8 degrees Celsius

 Cold and clammy skin
 Weak in appearance
 Pallor and tired
Goals and Objectives:
Short term:
Within 8 hours of nursing intervention, the patient will be able to maintain core
temperature within normal range.
Long term:
The patient will be able to be free of seizure activity.
Nursing Interventions:
Independent:
1. Monitor core temperature by appropriate route.

2. Promote client safety such as skin protection from cold to observe safety
measures and maintain bedrest to reduce metabolic demands of oxygen
consumption.
3. Monitor V/S such as BP, PR, RR and output as it may occur to hypotension,
shock, dehydration and hypermetabolic state or seizure .
Dependent/Collaborative:
1. Administer antipyretics to control shivering and seizures.

2. Collaborative treatment of underlying condition or disease processes
causing fever, to approach for fever management to control the fever
occurred and as well tolerance for fever.
Evaluation:
GOALS MET. The patient was able to able to maintained core temperature
within normal range.
Priority problem #2: Constipation related to eating habit change and illness as
evidenced by hard-formed stool
Objective:
 Hard formed stool

 Inability to defecate
 Insufficient intake of foods
Short term:
Within 8 hours of nursing intervention, the patient will establish or regain normal
pattern of bowel functioning.
Long term:
The patient will be able to demonstrate behaviors or lifestyle changes to prevent

recurrence of problem.
Independent:
1. Identify elements that usually stimulate bowel activity.

2. Note color, odor, consistency, amount and frequency of stool as this
provides a baseline for comparison and promotes recognition of changes.
3. Promote adequate intake of fluids and high-fiber foods. Suggest drinking
warm or stimulating fluids.
4. Encourage the client to not ignore urge and provide privacy.
1. Administer or recommend medication such as stool softeners when

appropriate to prevent constipation.
2. Note the pharmacological agents the client used to determine the
effectiveness of current regimen.
Evaluation:
GOAL WAS NOT MET. The patient was not able to able to established or regained
normal pattern of bowel functioning.
Priority problem #3: Risk for bleeding related to platelet deficient blood products
Objective:
 Irritable
 Weak in appearance
 Restless
 Platelet count of 143,000
Short term:
Within 8 hours of nursing intervention, the patient will be free of signs of active
bleeding as evidenced by stable vital signs and urinary output.
Long term:
The patient will be able to display normalization of laboratory results for clotting
times and factors within normal range.
Independent:
1. Assess skin color and moisture, level of consciousness as it may indicate of blood
loss affecting circulation.
2. Restrict activity and encourage bedrest until bleeding abates
3. Note client report of pain in specific areas as this can help to identify bleeding into
tissues, organs or body activities.
1. Collaborate in evaluating the need for replacing blood loss or specific
components and be prepared for emergency interventions.
2. Assist in administering hemostatic agents if needed to promote clotting and
diminish bleeding.
Evaluation:
GOALS MET. The patient was able to be freed of signs of active bleeding as
evidenced by stable vital signs and urinary output.
DISCHARGE PLAN
Goals:
Upon Discharge:
 The patient‘s parents will fully understand the prognosis and further home
management and therapies in order to provide the possible care needed by the
child.
 They will be able to prevent the occurrence of complications and support
recuperative process of the patient‘s condition.
Medication
 Instruct the patient’s guardians to follow the entire course of prescribed

medications according to the doctor‘s order for the first few days after discharge.
 Instruct the guardians the importance of following the right dosage and the correct
timing of the medications as prescribed.
 Explain to the parents the purpose, indications and, adverse effects of the
prescribed medications.
Economy/Exercise
 Encourage the parents to look for cheaper sources of medications to avoid

financial difficulties.
 Instruct the parents to let the patient have adequate sleep that is importance in the
healing process.
Treatment/Therapy
 Give the parents verbal and written instructions with regards to continuing home
medications given by the physician and its importance of compliance with such
medications. Teach the parents about the importance of making and keeping
follow-up appointments.
 Explain to them the importance of home medications as prescribed by the doctor.
 Instruct parents to continue and complete all the medicines at home and when and
how to give those.
Health Teachings/Hygiene
Health teachings imparted to the parents:

 Emphasize the necessity of giving the drugs or medication as prescribed by the
physician. Premature discontinuation of treatment may result in resistance to drug
and other potential complications.
 Give emphasis on the importance of proper nutrition for the patient.
 Patient should be positioned for comfort and provided with adequate rest periods
to maintain progress towards full recovery.
 Tell parents to avoid exposing the patient to an environment that will only impose
further complications.
 Instruct the patient to not leave a clean stored water in their areas without covering
it and instruct to clean their area to be free from dengue mosquitoes.
Consultation
 Instruct the guardians about the importance of regular check-up and for any follow
up visit to any health care provider, to continuously assess the patient condition.
Diet
 Emphasize to guardians the importance of vitamin and mineral supplements to
boast inadequate immunity of the patient.
Spiritual
 Encourage patient and family members to strengthen their relationship to God, to
maintain religious practices and beliefs.
 Advise family members to provide emotional support to the client to help her know
that she will always have help during most difficult times.

Case Study

Uploaded by

Copyright:

Available Formats

Case Study

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Case Study

Uploaded by

Copyright:

Available Formats

Capitol University

Cagayan de Oro City

In Partial Fulfillment of the requirement of RLE 109 – Northern Mindanao Medical

Second Rotation (Pediatric – Dengue Ward)

Ms. Fredelina S. Chua, RN. MN

Background of the study 5

Scope and Limitations of the study 6

Significance of the study 7

Objectives of the study 10

Health Pattern Assessment & Health History 13

Anatomy & Physiology 28

Evaluation, Results, Discussion 59

Related Learning Experience 60

According to World Health Organization, Dengue is fast emerging pandemic-

Severe dengue is a potentially fatal complication, due to plasma leaking, fluid

Severe dengue (previously known as dengue haemorrhagic fever) was first

In humans recovery from infection by one dengue virus provides lifelong

Dengue fever, an Aedes mosquito-borne viral disease, is widespread in Singapore,

This study focuses and is limited only to Severe Dengue. It is composed of

CASEY’S MODEL OF NURSING

Anne Casey is an English nurse who developed a nursing theory known as

Pediatric nurses work in pediatrician’s clinics as well as hospitals and specialized

Betty Neuman’s Systems Model provides a comprehensive holistic and system-

 Primary prevention is applied in patient assessment and intervention, in identification

 Secondary prevention relates to symptomatology following a reaction to stressors,

 Tertiary prevention relates to adjustive processes taking place as reconstitution

 The patient is in dynamic, constant energy exchange with the environment.

The student nurse aims to:

1. Accurately present a thorough general assessment of the client which introduces

Nursing Health History

Day Vital Signs

PR RR Temperature Blood Oxygen

1st day of 7 25 38.8 degrees 98%

2nd day of 89 24 36.3 degrees 90/60 98%

History of Present Illness

Child X, at age of 3 years old. 4 days prior to admission, patient

Patient Health History

Child X had a previous admission and hospitalization at Gingoog Hospital last

Maternal and Paternal Health History

The patient has a family history of gallstone and GERD.

Patient’s General Appearance

Functional Health Pattern

Done during initial assessment: (December 1, 2019)

Nutritional and Metabolic Pattern

Before hospitalization, Child X usually defecates one times a day or defecates

Done during initial assessment (December 1, 2019)

ACTIVITIES OF DAILY LIVING FUNCTIONAL SCORE

Feeding Assist with person 2

Bathing Assist with person 2

Dressing Assist with person 2

Grooming Assist with person 2

Meal Preparation Total Dependence 4

Cleaning Total Dependence 4

Toileting Assist with person 2

Bed Mobility Independent 0

Chair/Toilet Transfer Assist with person 2

General Mobility Independent 0

Cognitive- Perceptual Pattern