I.

PERSONAL DATA

NAME: Angel Mae De Leon

ADDRESS: Cavinitan, Virac, Catanduanes
AGE: 42 years old
BIRTHDAY: January 6, 2006
SEX: Female
RELIGION: Roman Catholic
NATIONALITY: Filipino
CHIEF COMPLAINT: Fever
TENTATIVE DIAGNOSIS: DHF 2; ATP
FINAL DIAGNOSIS: DHF 2; ATP
DATE ADMITTED: September 9, 2010 @ 8:30 PM
ATTENDING PHYSICIAN: Dr. Advincula

II.PATIENT HEALTH
PRESENT HEALTH HISTORY:
HISTORY
August 10, 2010 at around 11:10 AM, while the patient is at home, he fills abdominal pain at right lower quadrant and vomits, which he become weak and
the pain he felt is not bearable.
At the ER, Dr. Advincula received and examined the patient thoroughly and ordered to be admitted for further management and evaluation.

PAST HEALTH HISTORY:

Delfin Arcilla Jr., 42 years old, male , married and a resident of Pajo, San Isidro, Virac, Catanduanes. According to him, he was hospitalized due to vehicular
accident, had a previous operation due to stab wound last 1995 and has a history if hypertension on mother side. He consumed 7 sticks of cigarettes per day and
alcohol three times a week.
III.DEVELOPMENTAL
TASK:

Preschooler
Initiative vs Guilt
Begins to initiate, not imitate, activities; develops
conscience and sexual identity

IV.ANATOMY AND
PHYSIOLOGY:
 V.PATHOPHYSIOLO

GY: Aedes Aegypti

 Dengue Virus Type I
(Chikungunya Virus)

IgG adheres to the platelet

(initiates destruction of the platelet)

thrombocytopenia
(50,000/mm3 or less)

increased potential
for hemorrhage

stimulates intense
inflammatory response

petechial rash, high fever, headache

(epistaxis, vomiting, conjunctival infection,
abdominal pain, shock, death)

VI.DIAGNOSTIC EXAM:
 TEST RESULT NORMAL VALUES CLINICAL SIGNIFICANCE

RBC
4.76
WBC COUNT
3.5 x 10g/L 5.10 x 10g/L
Indicates presence of infection.
PLATELET
384 X 10 g/L 150-450 x 10g/L Normal

VII.DRUG STUDY
Medicine Dosage / Route of Indication Contraindication Adverse Reaction Nursing Considerations
Administration
Cefuroxime 250mg TIV q8  Lower respiratory  Contraindicated  CNS: Headache,  HISTORY: Liver and
infections caused with allergy to dizzeness, lethargy, renal dysfunction,
by S.pnemoniae, cephalosporins or paresthesias lactation,
S.aureus, E. coli, penicillins.  GI: Nausea , pregnancy
Klebsiella,H,  Use cautiously with vomiting, diarrhea,  PHYSICAL: Skin
influenza, renal failure, anorexia, status, LFTs, renal
S,pyogenes. lactation, abdominal function tests,
 Dermatologic pregnancy. pain,flatulence culture of affected
infections caused  GU: Nephrotoxicity area, sensitivity
by S. aureus, S.  HEMATOLOGIC: tests
 pyogenes, E. coli Bone marrow
Klebsiella, depression( decrea
Enterobacter sed WBC,
 UTIs caused by E. decreased
coli, Klebsiella platelets,
 Uncomplicated decreased
and disseminated hematocrits )
gonorrhea caused  LOCAL: Pain,
by N. abscess at injection
gonorrhoeace site, phlebitis,
 Septicemia caused inflammation at IV
by S. pneumonia, site
S. aureus, E. coli
,Klebsiella, H.
influenza
 Meningitis caused
by S. pneumonia,
H.influenzae,
S.aureaus, N.
meningitides
 Bone and joint
infections caused
by S.aureus
 Perioperative
prophylaxis
 Treatment of acute
bacterial maxillary
sinusitis in patients
3mo-12 yr
Paracetamol 1.5 m q4 T  Mild to moderate Hypersensitivity Hypersensitivity reactions
pain e.g. headache, e.g. skin rashes, drug fever.
toothache, Acute overdosage produces
myalgias.Fever.As a dose-dependent
alternative to potentially fatal
 aspirin in patients hepatocellular damage.
with viral infection,
peptic ulcer
disease, bronchial
asthma and
bleeding disorders.
VIII.NURSING CARE PLAN

Cues Nursing Diagnosis Scientific Objectives Nursing Interventions Rationale Evaluation

Inference
Subjective: Injury, risk for Mosquito bite After 1 hr. Of  Assess for  The G.I tract After 1 hr. Of
hemorrhage nursing signs (esophagus and nursing
Objective: related to interventions, and symptoms of rectum) is the interventions,
 Weakness and altered clotting the client will G.I bleeding. most usual the client
irritability. factor. Infected blood be able to Check for source of was able to
 Restlessness. demonstrate secretions. bleeding of its demonstrate
 (+) skin rash  Skin behaviors Observe color mucosal behaviors
 V/S taken as pigmentation that reduce and consistency fragility. that reduce
follows: related to skin Fever (on & off the risk for of stools or the risk for
T: 38 rash bleeding. vomitus. bleeding.
P: 84
R: 28  Observe for  Sub-acute
(+)IgM presence of disseminated
petechiae, intravascular
ecchymosis, coagulation
bleeding from one (DIC) may
(+) dengue test more sites. develop
secondary to
altered clotting
factors.
 Monitor pulse  An increase
Blood in pulse with
pressure. decreased
 Blood
pressure
can indicate
loss of
circulating
blood
volume.
 To prevent
 Increase fluid dehydration
intake.
 Changes
 Note changes may indicate
in mentation cerebral
and level of perfusion
consciousness secondary
. to
hypovolemia
hypoxemia.

 Rectal and
 Avoid rectal esophageal
temperature, vessels are
be gentle with most
GI tube vulnerable
insertions. to rupture.

 In the
 Encourage use presence of
of soft tooth- clotting factor
brush, avoiding disturbances,
straining for minimal trauma
stool, and can cause
forceful nose mucosal
blowing. bleeding.


IX.DISCHARGE PLAN
M – edication

Intake of appropriate vitamin supplement and diuretics to increase protection mechanism of the immune system and decreases renal vascular resistance and
may increase renal blood flow, respectively.

E – conomic

The use of nonpharmacotherapy such as drinking plenty of water will promote increase plasma in blood to increase immunity and proper hygiene and
promotion of cleanliness at home and work area.
T – reatment

Management of such condition would be through hydration and doing control measures to eliminate vector by promoting cleanliness in the environment
through proper disposal of rubber tires, changing of water of lower vases once a week, destruction of breeding places of mosquito and residual spraying with
insecticides.

H – ygiene

Advise to follow proper body hygiene and to maintain cleanliness on surroundings. This would prevent additional cases of DHF.

O – ut Patient/ Follow-up

Any odd signs such as fever, petechiae, recurrence of fever,etc. must be immediately reported to the physician.

D – iet

Instruct to eat foods that are low fat, low fiber, non-irritating and non-carbonated.

X.IMPLICATION
NURSING PRACTICE:

The implication of this study in regards with nursing practice is the utilization of nursing concepts, which includes nursing care plan, nursing

process etc. This is important in nursing practice because in this stage where nursing interventions are implemented and done in order to promote

wellness in the patient and also to broaden the concept of the student nurse in rendering care. In this way, the student nurse will be able to prioritize

his or her focus of care and apply the principles in the clinical setting, which he or she learns. Nursing is planning. It is essential because it aids the
student in critical thinking skills. Prioritizing care, which learned, developed and evolved in this phase. The ever-changing role of the nurses in terms

of giving care plays an important role in caring for the sick. Its role is to broaden the knowledge of the people in terms of the importance prevention

and compliance to therapeutic regimen to restore the good health to patients. As a conclusion, the student nurses can emphasize their skills in terms

of giving care. The important is to serve and give care even in the evolution of trends and technology of new care settings and the changes and

acceptance of roles of the nurses in the nursing field of care.

NURSING RESEARCH:

Every day, illnesses and disease conditions continue to evolve to the next level. And same can be said to interventions and medications to treat these

conditions. In order to come up with these said interventions and medications, the facts of the previous disease conditions are used as basis. And so I consider

this case study as an important part of this research. I believe that this case study will help researchers discover something that will not only treat a disease but

more importantly on how to prevent acquiring diseases. This case study is important for us to know more about acid peptic disease and how to deal with it.

Therefore, we must be open minded to whether old or new trends about things because this trends will always help us. Who knows, we might be able to discover

something new that will be of great help in the future just by giving time to read articles and books.

NURSING EDUCATION:

Our hunger for knowledge is insatiable. We continue to learn as we continue to live. So why not learn to be of help to everyone. The implication of this case

study to nursing education is to broaden, upgrade, and maximize the knowledge and skills of the nurses (especially the student nurses) in terms of caring patients
with acid peptic disease. Nursing is a never-ending educational challenge to nurses and to the other health care team members. Changes and evolution of care

concerning this kind of disease was brought about by the rapid change of technology nowadays. We all know that a good background about something is like a

good investment to our chosen profession. I believe that knowing about acid peptic disease will help us know what we should do and what attitude we should

make in dealing with clients having this kind of disease, since giving optimal care is one of our goals as nurses. We are dealing with lives, so every action we make

is very vital to our patient; therefore making mistakes can put our patient in grave danger. So to avoid making mistakes, it is good to have some foundation, some

knowledge. We play an important part in patients’ lives. So, we need to remember to be careful because we cannot always undo the things that we already did;

same as “We cannot bring back the dead to life.” Moreover, when reading this case study, this will help you not only become efficient but to be effective as well in

rendering care to patients especially to those patients with acid peptic disease.

Patient teaching home health guide

Health teachings were directed toward resulting the patient’s individual needs for knowledge of self-care and health maintenance activities. I,

as a student nurse, shared necessary health teachings to my patient. I discussed to him the importance of having adequate rest, avoiding stress and

having lifestyle modification like cessation of drinking alcoholic beverages. I stressed out to him the benefits he could get out from quitting smoking

and the reasons why he needs to do it. I encouraged him not to forget the medications prescribed by the physician. I also taught him on what kind of

food that he needs to be avoided, which includes the salty, spicy and acidic food, because these can stimulate acid secretion.