INTRODUCTION Dengue Fever i

INTRODUCTION

Dengue Fever is caused by one of the four closely related, but antigenically distinct, virus serotypes Dengue type 1, Dengue type 2, Dengue type 3, and Dengue type 4 of the genus Flavivirus and Chikungunya virus. Infection with one of these serotype provides immunity to only that serotype of life, to a person living in a Dengue-endemic area can have more than one Dengue infection during their lifetime. Dengue fever through the four different Dengue serotypes are maintained in the cycle which involves humans and Aedes aegypti or Aedes albopictus mosquito through the transmission of the viruses to humans by the bite of an infected mosquito. The mosquito becomes infected with the Dengue virus when it bites a person who has Dengue and after a week it can transmit the virus while biting a healthy person. Dengue cannot be transmitted or directly spread from person to person. Aedes aegypti is the most common aedes specie which is a domestic, day-biting mosquito that prefers to feed on humans.

INTUBATION PERIOD: Uncertain. Probably 6 days to 10 days

PERIOD OF COMMUNICABILITY: Unknown. Presumed to be on the 1st week of illness when virus is still present in the blood

CLINICAL MANIFESTATIONS:

First 4 days:
>febrile or invasive stage — starts abruptly as high fever, abdominal pain and headache; later flushing which may be accompanied by vomiting, conjunctival infection and epistaxis
4th to 7th day:
>toxic or hemorrhagic stage — lowering of temperature, severe abdominal pain, vomiting and frequent bleeding from GIT in the form of melena; unstable BP, narrow pulse pressure and shock; death may occur; vasomotor collapse
7th to 10th day:
>convalescent or recovery stage — generalized flushing with intervening areas of blanching appetite regained and blood pressure already stable

MODE OF TRANSMISSION:

Dengue viruses are transmitted to humans through the infective bites of female Aedes mosquito. Mosquitoes generally acquire virus while feeding on the blood of an infected person. After virus incubation of 8-10 days, an infected mosquito is capable, during probing and blood feeding of transmitting the virus to susceptible individuals for the rest of its life. Infected female mosquitoes may also transmit the virus to their offspring by transovarial (via the eggs) transmission.

Humans are the main amplifying host of the virus. The virus circulates in the blood of infected humans for two to seven days, at approximately the same time as they have fever. Aedes mosquito may have acquired the virus when they fed on an individual during this period. Dengue cannot be transmitted through person to person mode.

CLASSIFICATION:

1. Severe, frank type
>flushing, sudden high fever, severe hemorrhage, followed by sudden drop of temperature, shock and terminating in recovery or death
2. Moderate
>with high fever but less hemorrhage, no shock present
3. Mild
>with slight fever, with or without petichial hemorrhage but epidemiologically related to typical cases usually discovered in the course of invest or typical cases
GRADING THE SEVERITY OF DENGUE FEVER:

Grade 1:
>fever
>non-specific constitutional symptoms such as anorexia, vomiting and abdominal pain
>absence of spontaneous bleeding
>positive tourniquet test
Grade 2:
>signs and symptoms of Grade 1: plus
>presence of spontaneous bleeding: mucocutaneous, gastrointestinal
Grade 3:
>signs and symptoms of Grade 2 with more severe bleeding: plus
>evidence of circulatory failure: cold, clammy skin, irritability, weak to compressible pulses, narrowing of pulse pressure to 20 mmhg or less, cold extremities, mental confusion
Grade 4:
>signs and symptoms of Grade 3, declared shock, massive bleeding, pulse less and arterial blood Pressure = 1 mmhg (Dengue Syndrome/DS)

SUSCEPTABILITY, RESISTANCE, AND OCCURRENCE:

>all persons are susceptible
>both sexes are equally affected
>age groups predominantly affected are the pre-school age and school age
>adults and infants are not exempted
>peak age affected: 5-9 years old

DF is sporadic throughout the year. Epidemic usually occurs during rainy seasons (June – November). Peak months are September – October. It occurs wherever vector mosquito exists.

DIAGNOSTIC TEST:

Tourniquet test
>Inflate the blood pressure cuff on the upper arm to a point midway between the systolic and diastolic pressure for 5 minutes.
>Release cuff and make an imaginary 2.5 cm square or 1 inch square just below the cuff, at the antecubital fossa.
>Count the number of petechiae inside the box. A test is positive when 20 or more petechiae per suare are observed.

Dengue haemorrhagic fever (DHF), a potentially lethal complication, was first recognized in the 1950s during the dengue epidemics in the Philippines and Thailand, but today DHF affects most Asian countries and has become a leading cause of hospitalization and death among children in several of them.

Last June 16, 2008, I encountered a patient with such kind of infection. This patient has caught my attention and has given the opportunity to study his case. The objective of this study is to help me understand the disease process of Dengue Fever and to orient myself for appropriate nursing interventions that I could offer to the patient. This approach enables me to exercise my duties as student nurse which is to render care. I was given the chance to improve the quality of care I can offer and to pursue my chosen profession as future nurse.

I humble myself to present my studied case and submit myself for further corrections to widen the scope of my knowledge and understanding.
DENGUE PREVENTION:
There is no vaccine to prevent dengue. Prevention centers on avoiding mosquito bites when traveling to areas where dengue occurs and when in U.S. areas, especially along the Texas-Mexico border, where dengue might occur. Eliminating mosquito breeding sites in these areas is another key prevention measure.
Avoid mosquito bites when traveling in tropical areas:
* Use mosquito repellents on skin and clothing.
* When outdoors during times that mosquitoes are biting, wear long-sleeved shirts and long pants tucked into socks.
* Avoid heavily populated residential areas.
* When indoors, stay in air-conditioned or screened areas. Use bednets if sleeping areas are not screened or air-conditioned.
* If you have symptoms of dengue, report your travel history to your doctor.
Eliminate mosquito breeding sites in areas where dengue might occur:
* Eliminate mosquito breeding sites around homes. Discard items that can collect rain or run-off water, especially old tires.
* Regularly change the water in outdoor bird baths and pet and animal water containers.

PATIENT’S PROFILE

NAME : Jay-Mark Legisniana Lorenzo

AGE : 8 y/o

GENDER : Male

ADDRESS : 022 Libertad St. Centro, Solana

DATE OF BIRTH : January 08, 2000

PLACE OF BIRTH : Solana, Cagayan

OCCUPATION : N/A (still a student)

NATIONALITY : Filipino

CIVIL STATUS : Single

RELIGION : Roman Catholic

CHIEF COMPLAINT : Fever

FINAL DIAGNOSIS : Dengue Fever

ATTENDING PHYSICIAN : Dra. Magdalena Velarde

DATE ADMITTED : June 14, 2008

TIME ADMITTED : 2:30 PM

ADMITTING INSTITUTION: Saint Paul Hospital
NURSING HISTORY

Present Health History:

Three days prior to admission the patient has fever and loss his appetite. According to the SO of the patient, they went to consult a physician during the first day of his fever. The physician prescribed Paracetamol for the patient. On the third day, the patient still had the said symptoms. He went back for a check-up. He had CBC and was determined that he has dengue. The patient then was admitted immediately to Saint Paul Hospital on June 14, 2008.

Past Health History:

According to the SO of the patient the patient did not yet experienced having serious health problems other than fever, colds and cough. He had no previous hospitalization.

Family Health History:

According to the SO of the patient, their family has the history of Hypertension.
GORDON’S 11 FUNCTIONAL HEALTTH PATTERN

HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

Before hospitalization:
The patient perceived his health in the state of good condition. He perceives health as wealth and he values his health a lot. He manages his health by practicing proper hygiene and eating nutritious food.

During hospitalization:
He sees himself as a total ill person because he cannot do anymore the things he usually does like playing with his siblings. He rely his present condition with the help of the therapeutic personnel and by following the prescribed medications. The patient perceived that he is not healthy because of his condition.

NUTRITIONAL-METABOLIC PATTERN

Before hospitalization:
The patient eats 3 times a day and with afternoon snacks after coming from school. According to the SO of the patient, he eats meat, fish and also vegetables. He doesn’t have any allergies on foods and drugs. His appetite is moderate and usually depends on the food being served. He didn’t complain any difficulty in swallowing.

During hospitalization:
The patient has loss his appetite and hasn’t eaten a lot. He is on a DAT (Diet as Tolerated) EDCF (Except Dark Colored Foods).

ELIMINATION PATTERN

Before hospitalization:
The patient does not have any problem on his elimination pattern. He usually urinates 4-5 times a day without any difficulty. He added that the color of his urine is light yellow. He didn’t feel any pain in urination. The patient defecates once a day usually early in the morning before going to school with yellow to brown color. He verbalized that sometimes however, it is hard in consistency with dark color, which generally depends on what he eats.

During hospitalization:
The patient urinates 2-3 times a day. The color of her urine is yellow. The patient defecates once every two days.

ACTIVITY-EXERCISE PATTERN

Before hospitalization:
He could perform activities of his daily living. According to him, he often plays with his siblings and this serves as a form of exercise for him.

During hospitalization:
His activity was limited lying on bed but the patient is given his bathroom privileges.

SLEEP-REST PATTERN

Before hospitalization:
He has the normal 6-8 hours sleep. He also has his nap time for 1-2 hours a day. Sleeping and watching the television are his form of rest.

During hospitalization:
He doesn’t have the adequate time of sleep since he is disturbed with the nurses that enter the room every now and then, and because of the environmental changes of his surroundings. He also has inadequate time to rest since he doesn’t have enough time to sleep.

COGNITIVE-PERCEPTUAL PATTERN

Before hospitalization:
He is normal in terms of his cognitive abilities. He has good memory and reasoning skills. He can easily comprehend on things. In terms of his perceptual pattern, he has no problems with his senses.

During hospitalization:
He was normal as before in his cognitive and perceptual pattern. He responds clearly and well understood. He has no sensory deficit; He responds appropriately to verbal and physical stimuli and obeys simple commands.
SELF-PERCEPTION – SELF-CONCEPT PATTERN

He sees himself as a person with a good personality. He has been a good friend, brother and a son. He said he has to be a good person in order not to hurt others. He also describes himself as a typical type of student and person.

ROLE-RELATIONSHIP PATTERN

Before hospitalization:
He has a close relationship with his family. They were five siblings in their family. He was at the middle. I was also able to ask his mother about his being a son and she confessed that he is a good son but at times he doesn’t obey her. He is also a responsible student and knows all his duties as a friend.

During hospitalization:
He had more time to bond with his family. He said that it was a nice feeling to know that your family is so supportive to him. He learned to appreciate the beauty of having a family that gives you strength and support no matter what.

SEXUALITY-REPRODUCTIVE PATTERN

According to him, he doesn’t think of the things like having a girlfriend and getting married yet. He is still young for such matters.

COPING-STRESS TOLERANCE PATTERN

Before hospitalization:
He does not fully identify his situations having stress but he always tell her parents when something is wrong.

During hospitalization:
He shares his problems to his family. He verbalizes his feelings.

VALUE-BELIEF PATTERN
He is a Roman Catholic devotee. He always goes with his family every Sunday to go to mass. He was taught by his family to believe and have fear to GOD. They usually believe in quack doctors.

PHYSICAL ASSESSMENT

Date assessed: June 18, 2008
General assessment: conscious and coherent
Initial vital signs: T=36.2° C, RR=23, BP=90/60, PR=70

Area Assessed Technique Normal Findings Actual Findings Evaluation Skin
Color
Inspection
Light brown, tanned skin (vary according to race)
Light brown skin
Normal Soles and palms Inspection Lighter colored palms, soles Lighter colored palms, soles Normal Moisture Inspection/
Palpation Skin normally dry Skin normally dry Normal Temperature Palpation Normally warm Normally warm Normal Texture Palpation Smooth and soft Smooth and soft Normal Turgor Palpation Skin snaps back immediately Skin snaps back immediately Normal Skin appendages
a. Nails

Inspection

Transparent, smooth and convex

Transparent, smooth and convex

Normal Nail beds Inspection Pinkish Pale Due to decreased blood flow Nail base Inspection Firm Firm Normal

Capillary refill

Inspection/ Palpation White color of nail bed under pressure should return to pink within 2-3 seconds Returns within 2-3 seconds Normal b. Hair
Distribution
Inspection
Evenly distributed
Evenly distributed
Normal Color Inspection Black Black Normal Texture Inspection/ Palpation Smooth Smooth Normal Eyes
Eyes
Inspection
Parallel to each other
Parallel to each other
Normal Visual Acuity Inspection (penlight) PERRLA- Pupils equally round react to light and accommodation PERRLA- Pupils equally round react to light and accommodation Normal Eyebrows Inspection Symmetrical in size, extension, hair texture and movement Symmetrical in size, extension, hair texture and movement Normal Eyelashes Inspection Distributed evenly and curved outward Distributed evenly and curved outward Normal Eyelids Inspection Same color as the skin

Blinks involuntarily and bilaterally up to 20 times per minute

Do not cover the pupil and the sclera, lids normally close symmetrically Same color as the skin

Blinks involuntarily and bilaterally up to 18 times per minute

Do not cover the pupil and the sclera, lids normally close symmetrically Normal

Normal

Normal Conjunctiva Inspection Transparent with light pink color Transparent with light pink color Normal Sclera Inspection Color is white Color is white Normal Cornea Inspection Transparent, shiny Transparent, shiny Normal Pupils Inspection Black, constrict briskly Black, constrict briskly Normal Iris Inspection Clearly visible Clearly visible Normal Ears
Ear canal opening
Inspection
Free of lesions, discharge of inflammation

Canal walls pink
Free of lesions, discharge of inflammation

Canal walls pink
Normal

Normal Hearing Acuity Inspection Client normally hears words when whispered Client normally hears words when whispered
Normal Nose
Shape, size and skin color
Inspection
Smooth, symmetric with same color as the face
Smooth, symmetric with same color as the face

Normal
Nares
Inspection
Oval, symmetric and without discharge
Oval, symmetric and without discharge

Normal Mouth and Pharynx
Lips

Inspection

Pink, moist symmetric

Light pink, dry, symmetric

Lack of fluid intake Buccal mucosa Inspection Glistening pink soft moist Glistening pink soft moist Normal Gums Inspection Slightly pink color, moist and tightly fit against each tooth Slightly pink color, moist and tightly fit against each tooth
Normal Tongue Inspection Moist, slightly rough on dorsal surface medium or dull red Moist, slightly rough on dorsal surface medium or dull red
Normal Teeth Inspection Firmly set, shiny Firmly set, shiny
With tooth decay Normal Hard and soft palate Inspection Hard palate- dome-shaped
Soft Palate- light pink Hard palate- dome-shaped
Soft Palate- light pink
Normal Neck
Symmetry of neck muscles, alignment of trachea

Inspection
Neck is slightly hyper extended, without masses or asymmetry
Neck is slightly hyper extended, without masses or asymmetry

Normal Neck ROM Inspection Neck moves freely, without discomfort Neck moves freely, without discomfort Normal Thyroid gland Palpation Rises freely with swallowing Rises freely with swallowing Normal Thorax and Lungs Auscultation Clear breath sounds Clear breath sounds Normal Abdomen

Bowel sounds Inspection

Auscultation Skin same color with the rest of the body
Clicks or gurling sounds occur irregularly and range from 5-35 per minute Skin same color with the rest of the body
Clicks or gurling sounds occur irregularly and range from 20 per minute Normal

Normal
Extremities

Symmetry

Skin color

Hair distribution

Skin Temperature

Presence of lesion
ROM
Inspection

Inspection

Inspection

Palpation
Inspection

Inspection
Symmetrical

Same with the color of other parts of the body

Evenly distributed

Warm to touch
No lesions

Moves freely without discomfort
Symmetrical

Same with the color of other parts of the body

Evenly distributed

Warm to touch
No lesions

Able to move but with assistance
Normal

Normal

Normal

Normal
Normal

Due to body weakness
Neurology system
Level of consciousness

Inspection

Fully conscious, respond to questions quickly, perceptive of events

Fully conscious, respond to questions quickly perceptive of events
Normal Behavior and appearance Inspection Makes eye contact with examiner, hyperactive expresses feelings with response to the situation Makes eye contact with examiner, hyperactive expresses feelings with response to the situation

Normal

LABORATORY EXAMINATIONS

HEMATOLOGY REPORT
Date: June 14, 2008

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS White Blood Cells 5-10 x 10^g/L 3.9 x 10^g/L Decreased due to inadequate inflammatory defenses to suppress infection and humoral immunity takes place Hemoglobin M: 13.0-18.0 g/dL 10.2 g/dL Decreased due to poor oxygen supply Hematocrit 39-54 % 31 % Decreased due to poor oxygen supply Segmenters 0.60-0.70 0.73 Increased; indicate high glucose level in the blood Lymphocytes 0.20-0.30 0.27 normal Platelet Count 150-450 x 10^g/L 163 x 10^g/dL Normal
HEMATOLOGY REPORT
Date: June 15, 2008, AM

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS White Blood Cells 5-10 x 10^g/L 2.9 x 10^g/L Decreased due to inadequate inflammatory defenses to suppress infection and humoral immunity takes place Hemoglobin M: 13.0-18.0 g/dL 9.5 g/dL Decreased due to poor oxygen supply Hematocrit 39-54 % 29 % Decreased due to poor oxygen supply Segmenters 0.60-0.70 0.65 Normal Lymphocytes 0.20-0.30 0.35 Increased due to the body’s increased immune system Platelet Count 150-450 x 10^g/L 145 x 10^g/dL Hemolysis ABO/ Rh Type: O Rh positive

FECALYSIS REPORT
Date: June 15, 2008

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS Physical Properties
Color
Yellow
Brown
Due to the presence of bacteria Consistency Semi-formed Loose Due to presence of bacteria Bacteria: Occasional
Occult Blood: Negative
Remarks: No ova/intestinal parasite seen

URINALYSIS REPORT
Date: June 15, 2008

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS Color Yellow Amber Yellow normal Transparency Clear to slightly turbid clear normal Reaction 4.5-8 6.5 normal Specific Gravity 1.005-1.030 1.020 normal Sugar Negative Negative normal Protein Negative Negative normal Squamous Epithelial Cells Few Occasional normal Red Blood Cells Few 0-2 normal Pus Cells Few 0-2 normal Amorp. Urates/Phosphates Few Occasional normal
HEMATOLOGY REPORT
Date: June 15, 2008, PM

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS White Blood Cells 5-10 x 10^g/L 2.7 x 10^g/L Decreased due to inadequate inflammatory defenses to suppress infection and humoral immunity takes place Hemoglobin M: 13.0-18.0 g/dL 9.5 g/dL Decreased due to poor oxygen supply Hematocrit 39-54 % 29 % Decreased due to poor oxygen supply Segmenters 0.60-0.70 0.68 normal Lymphocytes 0.20-0.30 0.32 Increased due to the body’s increased immune system Platelet Count 150-450 x 10^g/L 125 x 10^g/dL hemolysis
HEMATOLOGY REPORT
Date: June 16, 2008, AM

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS White Blood Cells 5-10 x 10^g/L 3 x 10^g/L Decreased due to inadequate inflammatory defenses to suppress infection and humoral immunity takes place Hemoglobin M: 13.0-18.0 g/dL 9.7 g/dL Decreased due to poor oxygen supply Hematocrit 39-54 % 29 % Decreased due to poor oxygen supply Segmenters 0.60-0.70 0.69 normal Lymphocytes 0.20-0.30 0.36 Increased due to the body’s increased immune system Platelet Count 150-450 x 10^g/L 110 x 10^g/dL hemolysis
HEMATOLOGY REPORT
Date: June 16, 2008, PM

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS White Blood Cells 5-10 x 10^g/L 4.8 x 10^g/L Decreased due to inadequate inflammatory defenses to suppress infection and humoral immunity takes place Hemoglobin M: 13.0-18.0 g/dL 10.3 g/dL Decreased due to poor oxygen supply Hematocrit 39-54 % 31 % Decreased due to poor oxygen supply Segmenters 0.60-0.70 0.57 Decreased; indicate low glucose level in the blood Lymphocytes 0.20-0.30 0.43 Increased due to the body’s increased immune system Platelet Count 150-450 x 10^g/L 95 x 10^g/dL hemolysis
HEMATOLOGY REPORT
Date: June 17, 2008, AM

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS White Blood Cells 5-10 x 10^g/L 5 x 10^g/L Normal Hemoglobin M: 13.0-18.0 g/dL 10 g/dL Decreased due to poor oxygen supply Hematocrit 39-54 % 30 % Decreased due to poor oxygen supply Segmenters 0.60-0.70 0.68 Normal Lymphocytes 0.20-0.30 0.32 Increased due to the body’s increased immune system Platelet Count 150-450 x 10^g/L 85 x 10^g/dL hemolysis
HEMATOLOGY REPORT
Date: June 17, 2008, PM

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS White Blood Cells 5-10 x 10^g/L 10 x 10^g/L Normal Hemoglobin M: 13.0-18.0 g/dL 11.4 g/dL Decreased due to poor oxygen supply Hematocrit 39-54 % 35 % Decreased due to poor oxygen supply Segmenters 0.60-0.70 0.53 Decreased; indicate low glucose level in the blood Lymphocytes 0.20-0.30 0.47 Increased due to the body’s increased immune system Platelet Count 150-450 x 10^g/L 101 x 10^g/dL hemolysis
REVIEW OF ANATOMY AND PHYSIOLOGY

BLOOD

Blood is considered the essence of life because the uncontrolled loss of it can result to death. Blood is a type of connective tissue, consisting of cells and cell fragments surrounded by a liquid matrix which circulates through the heart and blood vessels. The cells and cell fragments are formed elements and the liquid is plasma. Blood makes about 8% of total weight of the body.

Functions of Blood:
>transports gases, nutrients, waste products, and hormones
>involve in regulation of homeostasis and the maintenance of PH, body temperature, fluid balance, and electrolyte levels
>protects against diseases and blood loss

PLASMA

Plasma is a pale yellow fluid that accounts for over half of the total blood volume. It consists of 92% water and 8% suspended or dissolved substances such as proteins, ions, nutrients, gases, waste products, and regulatory substances.

Plasma volume remains relatively constant. Normally, water intake through the GIT closely matches water loss through the kidneys, lungs, GIT and skin. The suspended and dissolved substances come from the liver, kidneys, intestines, endocrine glands, and immune tissues as spleen.

FORMED ELEMENTS

Cell Type Description Function Erythrocytes (RBC) Biconcave disk, no nucleus, 7-8 micrometers in diameter Transport oxygen and carbon dioxide Leukocytes (WBC):

Neutrophil
Basophil

Eosinophil
Lymphocyte

Monocyte

Spherical cell, nucleus with two or more lobes connected by thin filaments, cytoplasmic granules stain a light pink or reddish purple, 12-15 micrometers in diameter

Spherical cell, nucleus, with two indistinct lobes, cytoplasmic granules stain blue-purple, 10-12 micrometers in diameter

Spherical cell, nucleus often bilobed, cytoplasmic granules satin orange-red or bright red, 10-12 micrometers in diameter

Spherical cell with round nucleus, cytoplasm forms a thin ring around the nucleus, 6-8 micrometers in diameter
Spherical or irregular cell, nucleus round or kidney or horse-shoe shaped, contain more cytoplasm than lymphocyte, 10-15 micrometers in diameter

Phagocytizes microorganism
Releases histamine, which promotes inflammation, and heparin which prevents clot formation
Releases chemical that reduce inflammation, attacks certain worm parasites
Produces antibodies and other chemicals responsible for destroying microorganisms, responsible for allergic reactions, graft rejection, tumor control, and regulation of the immune system

Phagocytic cell in the blood leaves the circulatory system and becomes a macrophage which phagocytises bacteria, dead cells, cell fragments, and debris within tissues Platelet Cell fragments surrounded by a cell membrane and containing granules, 2-5 micrometers in diameter Forms platelet plugs, release chemicals necessary for blood clotting
PREVENTING BLOOD LOSS

When a blood vessel is damaged, blood can leak into other tissues and interfere with the normal tissue function or blood can be lost from the body. Small amounts of blood from the body can be tolerated but new blood must be produced to replace the loss blood. If large amounts of blood are lost, death can occur.

BLOOD CLOTTING

Platelet plugs alone are not sufficient to close large tears or cults in blood vessels. When a blood vessel is severely damaged, blood clotting or coagulation results in the formation of a clot. A clot is a network of threadlike protein fibers called fibrin, which traps blood cells, platelets and fluids.

The formation of a blood clot depends on a number of proteins found within plasma called clotting factors. Normally the clotting factors are inactive and do not cause clotting. Following injury however, the clotting factors are activated to produce a clot. This is a complex process involving chemical reactions, but it can be summarized in 3 main stages; the chemical reactions can be stated in two ways: just as with platelets, the contact of inactive clotting factors with exposed connective tissue can result in their activation. Chemicals released from injured tissues can also cause activation of clotting factors. After the initial clotting factors are activated, they in turn activate other clotting factors. A series of reactions results in which each clotting factor activates the next clotting factor in the series until the clotting factor prothrombin activator is formed. Prothrombin activator acts on an inactive clotting factor called prothrombin. Prothrombin is converted to its active form called thrombin. Thrombin converts the inactive clotting factor fibrinogen into its active form, fibrin. The fibrin threads form a network which traps blood cells and platelets and forms the clots.

CONTROL OF CLOT FORMATION

Without control, clotting would spread from the point of its initiation throughout the entire circulatory system. To prevent unwanted clotting, the blood contains several anticoagulants which prevent clotting factors from forming clots. Normally there are enough anticoagulants in the blood to prevent clot formation. At the injury site, however, the stimulation for activating clotting factors is very strong. So many clotting factors are activated that the anticoagulants no longer can prevent a clot from forming.

CLOT RETRACTION AND DISSOLUTION

After a clot has formed, it begins to condense into a denser compact structure by a process known as clot retraction. Serum, which is plasma without its clotting factors, is squeezed out of the clot during clot retraction. Consolidation of the clot pulls the edges of the damaged vessels together, helping the stop of the flow of blood, reducing the probability of infection and enhancing healing. The damaged vessel is repaired by the movement of fibroblasts into damaged area and the formation of the new connective tissue. In addition, epithelial cells around the wound divide and fill in the torn area.

The clot is dissolved by a process called fibrinolysis. An inactive plasma protein called plasminogen is converted to its active form, which is called plasmin. Thrombin and other clotting factors activated during clot formation, or tissue plasminogen activator released from surrounding tissues, stimulate the conversion of plasminogen to plasmin. Over a period of a few days the plasmin slowly breaks down the fibrin.
DRUG STUDY

ISOPRINOSINE
Dosage : 2 tsp TID 250 mg
Classification: Antivirals
Indication:Rhinovirus; herpes genitalis; measles; encephalitis; influenza; herpes zoster; herpes simplex; type A & B hepatitis; AIDS related complex; neoplastic diseases; anergy and hypoergy prior to major surgery
Action:
>Synthetic antiviral: it stimulates T-lymphocytes; used for HIV and Hepatitis
>non-toxic immune system stimulant
Adverse Reactions:
>Transient increase in urine and serum uric acid level; very rarely skin rashes; pruritis; GI upset; nausea; fatigue; malaise
Contraindications:
>Hypersensitivity. Patients w/ adnormally low neutrophil counts (< 0.75 x 10×9/L), or abnormally low haemoglobin levels (< 7.5 g/dL or 4.65 mmol/L)
Nx Considerations:
>Monitor increase in serum uric acid level, gout, urolithiasis or renal dysfunction; pregnancy and lactation
>Monitor hematological parameters
Patient Teaching:
>Inform patient that the drug must be taiken 1 hour apart on an empty Stomach
>Instruct the patient to notify prescriber if unusual effects occurs

AMOXICILLIN
Dosage : 375 mg TID
Classification : Antibiotic
Indication: Infections due to susceptible strains; helicobacter pylori infections in combination with other agents; post-exposure prophylaxis against bacillus anthracis; Chlamydia trachomatis in pregnancy
Action: Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death
Adverse Reactions:
>CNS – lethargy, hallucinations, seizures
>GI – glossitis, stomatitis, gastritis, sore mouth, furry tongue (black hairy), nausea, vomiting, diarrhea (bloody), enterocolitis,pseudomembranous colitis, nonspecific hepatitis
>GU – nephritis
>Hematologic – anemia, thrombocytopenia, leucopenia, neutropenia, prolonged bleeding time
>Hypersensitivity – rash, fever, wheezing, anaphylaxis
>Others – superinfections: oral and rectal moniliasis, vaginitis
Contraindications:
>Contraindicated with allergy to cephalosporins or penicillins, or other allergens
>Use cautiously with renal disorders and lactation
Nx Considerations:
>Culture infected area prior to treatment; reculture area if response is not expected
>Give in oral preparations only; amoxicillin is not affected by food
>Continue therapy for at least 2 days after signs of infection have disappeared; continuation for 10 full days is recommended
>Use corticosteroids or antihistamines for skin reactions
Patient Teaching:
>Take this drug around-the-clock
>Take the full course of therapy; do not stop because you feel better
>This antibiotic is specific for this problem and should not be used to self-treat other infections
>Eat frequent small meals to avoid GI effects; frequent mouth care may prevent sore mouth
>Report unusual bleeding or bruising, sore throat, fever, rash, hives, severe diarrhea, difficulty of breathing

PARACETAMOL
Dosage: 250 mg/5ml q 4° RTC
Classification: Nonopioid Analgesics & Antipyretics
Indication: Mild pain or fever
Action: Produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulating center.
Adverse Reactions:
Hematologic: Hemolytic Anemia, Neutropenia, Leukopenia, Pancytopenia
Hepatic: Jaundice
Metabolic: Hypoglycemia
Skin: Rash, Urticaria
Contraindications:
> Contraindicated in patients hypersensitive to drug.
> Use cautiously in patients with long-term alcohol use because therapeutics doses cause hepatotoxicity in these patients.
Nx Considerations:
> ALERT: Many OTC and prescription products contain acetaminophen; be aware of this when calculating total daily dose.
> Use liquid form for children and patients who have difficulty in swallowing.
> In children, don’t exceed five doses in 24 hours.
Patient Teaching:
> Tell parents to consult prescriber before giving drug to children younger than age 2.
> Advise patient or parents that drug is only for short-term use; urge them to consult prescriber if giving to children for longer than 5 days or adults for longer than 10 days.
> ALERT: Advise patient or caregiver that many OTC products contain acetaminophen, which should be counted when calculating total daily dose.
> Tell patient not to use for marked fever (temperature higher than 103.1°F [39.5°C]), fever persisting longer than 3 days, or recurrent fever unless directed by prescriber.
> ALERT: Warn patient that high doses or unsupervised long-term use can cause liver damage. Excessive alcohol use may increase the risk of liver damage. Caution long-term alcoholics to limit acetaminophen intake to 2g/day or less.
> Tell breast-feeding woman that acetaminophen appears in breast milk in low levels (less than 1% of dose). Drug may be used safely if therapy is short-term and doesn’t exceed recommended doses.
Interactions
o Drug-Drug
– Barbiturates, Carbamazepine, Hydantoins, Rifampin, Sulfinpyrazone: high doses or long-term use of these drugs may reduce therapeutic effects and enhance hepatotoxic effects of acetaminophen. Avoid using together.
– Lamotrigine: may decrease lamotrigine level. Monitor patient for therapeutic effects.
– Warfarin: may increase hypoprothrombinemic effects with long-term use with high doses of acetaminophen. Monitor INR closely.
– Zidovudine: may decrease zidovudine effects. Monitor patient closely.
o Drug-Herd
– Watercress: may inhibit oxidative metabolism of acetaminophen. Discourage use together.
o Drug-Food
– Caffeine: may enhance analgesic effects of acetaminophen. Products may combine caffeine and acetaminophen for therapeutic advantage.
o Drug-Lifestyle
– Alcohol use: may increase risk of hepatic damage. Discourage use together.

RELESTAL
Dosage: 1 tsp every 6°
Classification: Antidiarrheals
Content: Dicycloverine HCl
Indication: Children’s cholic, functional gut disturbances, renal and biliary coloc
Administration: May be taken before or after meals
Contraindications: Closed-angle glaucoma; urinary or GI obstruction, intestinal atony, paralytic ileus, asthma, myasthenia gravis, ulcerative colitis, hiatus hernia, ulcerative colitis and hepatic or renal colic
Adverse Reactions: Increased intraocular pressure, cyclopegia, mydriasis, dry mouth, blurred vision, flushing, urinary hesitancy & retention, tachycardia, palpitations, constipation, elevated body temperature, CNS excitation, rash, vomiting, photophobia
Drug Interactions: Anticholinergic activity may be increased by other parasympatholytics.
Guanethidine, histamine and reserpine can antagonize the inhibitory effect of anticholinergics on gastric acid secretion.
Antacids may impair absorption.

PRED 10
Dosage: tsp 3x a day after meal
Classification: Corticosteroid Hormones
Content: Prednisone
Indication: Treatment of endocrine, rheumatic & hematologic disorders, allergic & edematous states, collagen, dermatologic & opth, resp & neoplastic diseases. Suppression of inflammatory disorders.
Administration: Take immediately after meals
Contraindications: Gastric and duodenal ulcers, systemic fungal & certain viral infections, glaucoma, psychoses or severe psychoneuroses; live vaccines; hypersensitivity to glucocorticoids
Special Precautions: Heart failure, recent MI or HTN, DM, epilepsy, glaucoma, hypothyroidism, hepatic failure, osteoporosis, peptic ulceration, psychoses or severe effective disorders & renal impairment
Adverse Reactions: Fluid, electrolyte, visual & psychic disturbances, Cushingoid state, hirsutism, growth retardation, skin atrophy, facial erythema, aseptic osteonecrosis, amenorrhea
Drug Interactions: Live vaccines

APPEBON
Dosage: 1 tsp BID
Classification: Appetite Stimulants
Content: Per 5 ml Buclizine HCl 5mg, vitamin B1 10 mg, vitamin B6 5mg, vitamin B12 25mcg, lysine HCl 500mg
Indication: Poor appetite, underweight, anorexia nervosa. For nutritional support in post-operative cases, metabolic disorders and convalescence
Administration: With food
Contraindications: Angle closure glaucoma, prostate hypertrophy & primary hemachromatosis
Special Precautions: May impair ability to drive or operate machinery; pregnancy
Adverse Reactions: Drowsiness & dulling of mental alertness, dry mouth, headache, nausea, jitteriness, tiredness
Drug Interactions: Reduce the effectiveness of levodopa; CNS depressants; alcohol
LEARNING FEEDBACK DIARY

NAME: Dorina Lorraine B. Binarao AREA: St. Paul Hospital Floor 1
CLINICAL INSTRUCTOR: Ms. Shane B. Santos, RN DATES: June 16, 17, 18, 23 & 24, 2008

OBJECTIVES:
At the end of the rotation, I will be able to:
> To upgrade my knowledge on clinical setting
> To familiarize myself with the hospital setting
> To deliver health care services.
> To build rapport with the patients, SOs, staff nurses, clinical instructor and student nurses.
> To enhance my skill on therapeutic communication

The first rotation of my duty was in St. Paul Hospital and unexpectedly my schedule is night shift. I’m nervous at the first night of duty because I still don’t know what to expect in a hospital setting. The first night was like an orientation for us. We were only tasked to do the vital signs taking and plotting. We weren’t allowed yet to do the charting and giving of medications.
The patients given to us were in the Holy Family Ward. My first patient was a three year old boy whose chief complaint was contusion hematoma. It was good that I was paired with a Chinese student because I have someone to help me in taking the vital signs. The only disadvantage of having paired with her is that it is difficult to explain everything to her because language difference.
Having a night duty has positive and negative factors. The positive or advantage of night duty is that you are not toxic with many things to do. At night shift, you also have the time to browse the chart of the patient. The negative or disadvantage part is that you have to make yourself awake for about eight hours. Another disadvantage is that it is difficult to interview and assess the patient because it is his/her time to sleep and rest. Interaction among the group is really needed to keep all of us awake.
In next nights of our duty, we had our patients staying in Sto. Niño Ward. We were already tasked to do charting. Doing the charting every night enhances my skill and ability in doing it. Interviewing the SOs of the patient assigned to me was not difficult because they were so cooperative and kind. I was lucky to have patients that don’t have lot of tantrums even if they are still kids.
Experiencing the clinical or hospital setting makes me feel excited of my future job. I believe that I must do everything correctly for the benefit of my patients. It is a good and relieving feeling that the patient you handle will be discharged immediately.
The most unforgettable experience of my first rotation of duty was that someone died. My heart that time was like stubbed with a knife that I can’t breathe. Through this case, I instilled in my mind that I must be relax and do the things necessary to revive a life. Panicking during such case will not do anything good.
The first rotation of duty had left me with so many experiences that taught me a lot of things to remember.
A
CASE STUDY
ON
DENGUE FEVER
Submitted by:
Dorina Lorraine B. Binarao
Vicky
(BSN3 RLE Group G)
Submitted to:
Ms. Shane B. Santos, RN