206385498 stab-wound

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Case Study on
STAB WOUND
Submittedby:
MALLAR, ADRIAN G.
SUBMITTEDTO:EMY LYNONG UNSON

I. PATIENT ASSESSMENT DATA BASE
A. GENERAL DATA
1. Patient’s Name: J.B
2. Address: Tarlac City, Tarlac
3. Age: 23 y/o
4. Sex: Male
5. Birth Date: November 4, 1991
6. Rank in the Family: eldest among four children
7. Nationality: Filipino
8. Civil Status: Single
9. Date of Admission: January 1, 2014 at 3:30 AM
10. Order of Admission:
 Admit to Surgery ward, Secure consent for admission,Diagnostic test: Complete Blood Count platelet count (CBC), Medications: D5 LRS
1000cc x 30 - 31 gtts/min, .
11. Admitting diagnosis: Dengue Fever Type 2
12. Attending Physician: Dr. Mendoza
B. CHIEF COMPLAINT:
Patient J.C patient was admitted to surgery with complain of multiple stab wound
C. HISTORY OF PRESENT ILLNESS:
Prior to admission patient was intoxicated, allegedly stabbed by known/unknown assailant sustaining multiple history/
D. PAST HEALTH HISTORY:
According to the patient, he frequently had colds, cough and fever. He never had operations or injuries. Every time he got sick, he would ask medicines
from their Health Center this includes Paracetamol.
E. FAMILY ASSESSMENT
NAME RELATION AGE SEX OCCUPATION
EDUCATIONAL
ATTAINMENT
E.B Mother 36y/o Female Housewife High school graduate
H.B Father 42y/o Male Family driver High school graduate
S.L 2ND Child 13y/o Female None
Grade 8 ongoing
school
D.L 3RD Child 2y/o Female None None

F. SYSTEMS REVIEW - Gordon’s 11 Functional Health Patterns
1. HEALTH PERCEPTION – HEALTH MANAGEMENT PATTERN: Patient perceived health as a very important aspect in life; He stated that,”Kailangan
natin pangalagaan at panatilihing malusog ang ating pangagatawan para maiwasan ang pagkakaroon ng karamdaman.”
2. NUTRITIONAL – METABOLIC PATTERN
The smell of food stimulates the appetite of the patient; he usually eats vegetables, fish, chicken and meat and drinks 11 glasses of water a day.
Appetite: he eats 1 whole of the food served.
Usual Daily Menu: Before confinement Usual Daily Menu: During confinement
Food: 1 -2 cups of Rice, Fish, Chicken, vegetables
- Pinakbet
- Dinengdeng
- Fried fish
- adobo
- 1 cup of rice. Egg, fish, vegetables
Water: 10-11 glasses of water per day
Beverage: pineapple juice
Water: 10-11 glasses of water per day
Beverage: he drinks soft drinks every other day or occasionally;
juice
3. ELIMINATION PATTERN
Bowel habits: defecates three times a day before confinement. But during confinement, he only defecate once during our rotation characterized as black
tarry formed stool.
Bladder: void 5-6 times during our shift.
Color: Yellowish color
Odor: Pungent
4. ACTIVITY – EXERCISE PATTERN: A. Self-Care Ability
Before confinement During Confinement
0- Feeding 0- Feeding
0- Toileting 0- Toileting
0- Dressing 0- Dressing
0- Bathing 0- Bathing
0- Bed Mobility 0- Bed Mobility
0-Grooming 0-Grooming
Legend:
O - Full self-care
II - Requires use of equipment or device
III - Requires assistance or supervision from another person
IV - Requires assistance or supervision from another person and
equipment or device
V - Is dependent and does not participate
5. COGNITIVE – PERCEPTUAL PATTERN
A. Hearing: there is no hearing impairment, can hear clearly and able to comprehend with instructions when asked.

B. Vision: there is no visual impairment before confinement.
C. Sensory Perception: The patient responded when tapped in the shoulder.
6. SLEEP – REST PATTERN:
Patient state that; “He usually sleeps 12midnight and wake up at 6 am before he confined. Now he is in the hospital he sleeps 9pm to 5am.
7. SELF – PERCEPTION AND SELF CONCEPT PATTERN:
The patient said that he is just simple and kind.
8. ROLE RELATIONSHIP PATTERN:
Initially, Patient J.B was able to do responsibilities as a oldest brother such as guiding his siblings by giving a piece of advice when they have a problem.
9. SEXUALLY – REPRODUCTIVE PATTERN:
Patient was circumcised when he was 11 years old.
10. COPING STRESS TOLERANCE PATTERN:
Patient frequently asks questions to minimize his anxiety or consults advise to his parents or siblings whenever he has a problem and base his decisions
on it.
11. VALUE – BELIEF PATTERN:
The patient is Catholic by faith but not an active church-goer. He doesn’t believe to any superstitious beliefs.
G. HEREDO – FAMILIAL ILLNESS:

H. DEVELOPMENTAL HISTORY
PATIENT
NO KNOWN HEREDITARY ILLNESS
MOTHER
FATHER
GRANDMOTHER (DECEASED)
NO HEREDITARY KNOWN ILLNESS
GRANDFATHER (DECEASED)
HYPERTENSION

THEORIST AGE SEX DEFINITION PATIENT DESCRIPTION
ERICKSON IDENTITY VS ROLE
CONFUSION
12-18 years old
Male
Significant relations: peer
groups and role model
Psychosocial virtues: fidelity
and loyalty
Maladaptations and
malignancies: fanaticism -
repudiation
Patient states that he can
make decisions on his
own especially with
regards to his education
and choosing friends.
KOHLBERG’S STAGES OF
MORAL DEVELOPMENT
Stage 6
Older than 12
Male Principled conscience
Universal ethical principle
orientation, child follows
standards of conduct
The patient knows what is
good to what is bad for
him and he always obeys
his parents whatever they
going to say to him.
FREUD
PUBERTY TO DEATH
Genital stage
12-18 years old
Male
Sexual pleasure through
genitals
Behaviors:
- Becomes
independent of
parents
- Responsible for self
- Develops sexual
identity, ability to love
and work
Patient is able to maintain
genital hygiene and
knows what the word sex
is.
PIAGET’S COGNITIVE
THEORY
FORMAL OPERATIONS
11-15 Years old
Male
 Reality, abstract
thought
 Can deal with past,
present and future
 Deductive reasoning
Able to comprehend and
follows instructions when
asked, can learn new
things easily.

I. PHYSICAL ASSESSMENT
A. General Survey
Patient is afebrile, conscious and cooperative. He can ambulate even without assistance and does not appear weak. He wears ordinary clothes such as
loose t-shirt and shorts. He is in medium frame. Has slight body odor and doesn’t have any deformities. BMI = 22.77 kg/m2 base on the formula weight in
kg/( height in meters)2 which is within normal range as shown in the table below.
Category BMI range – kg/m2
Very severely
underweight
less than 15
Severely
underweight
from 15.0 to 16.0
Underweight from 16.0 to 18.5
Normal (healthy from 18.5 to 25

B. Vital Signs:
Temperature: 36.5°C
Cardiac Rate: 77 bpm
Respiration: 32 bpm
Blood Pressure: 100/80 mmHg
C. Regional Exam:
1. Skin, Hair and Nails: The client’s skin is of normal racial tone which is brown. There were abrasion on the right thigh andthe back of the head . The
skin turgor is good and do not have any signs of dehydration. The body hair is evenly distributed while there were portion of hair at the back of the has
been shaved due to stab wound.
weight)
Overweight from 25 to 30
Obese Class I
(Moderately obese)
from 30 to 35
Obese Class II
(Severely obese)
from 35 to 40
Obese Class III
(Very severely
obese)
over 40

Hair is black and straight with a barber’s cut. No scalp lesions or flaking. Fine hair evenly distributed over arms bilaterally and sparsely on legs bilaterally.
There is scarcely hair noted on axilla and on chest, back or face.
The client’s nail shape is convex clubbing, not well-trimmed and slightly dirty. The nail is smooth and the nail bed is pink. The capillary refill is within 3
seconds and no beau’s line noted.
2. Eyes: patient has no complains of blurring of vision or any visul problems; the eye brows are evenly distributed. Eyelids have effectively closure. The
Blink response is bilateral, eye balls are symmetrical, bulbar conjunctiva is clear, the palpebral conjunctiva is pink and the sclera is white. The palpebral
slant is aligning with the tip of the pinna. The corneal sensitivity reflex is present cornea is transparent, the color of his eyes are brown, the shape are
equal, it is uniform in color. Pupils are equal in size. Pupils are equally round and reactive to light and accommodation. He can execute the occular
movements. He can recognize objects within 12-14 inches away. The lacrimal apparatus are moist and non-tender.
3. Nose: The color of the client’s nose is of racial tone which is brown. His septum is in the midline. The mucosa is pink; nostrils are both patent, nasal
flaring is absent. Landmarks are visible. Sinuses are non-tender.
4. Ears: The color of the ear is of normal racial tone which is brown, it is symmetrical. The alignment of the pinna is symmetrical. The pinnas are elastic
and recoil when folded. The mastoid process is non-tender. The auditory canal contains some cerumen, the color is brown and there is an absent of
discharges.
5. Mouth and throat: The lips is symmetrical and pink, the consistency is smooth, buccal mucosa is pink, the gum is pink, the tongue is in the midline,
the color is pink and it is smooth. The tongue movements are not that smooth. The color of the hard and soft palate is pink and is intact. The tonsils are
not inflamed. There is presence of mucous. Uvula is in the midline, gag reflex is present. The teeth has a complete set of 32 teeth, with some cavities on
the upper and lower molar tooth .
6. Neck and lymph nodes: no pulsations visible, no thyroid enlargement upon palpation and inspection. No tenderness noted.
7. Thorax and lungs: The color of the chest is of normal racial tone which is brown, the shape is AP to lateral ratio 1:2. There are absences of
intercostal retraction, costal angle is 45° chest wall are symmetrical, and the chest expansion is symmetrical. Rib slope is less than 90. Respiratory
rhythm is regular. The respiratory depth is shallow. Respiratory pattern is normal. When palpated she doesn’t feet any tenderness. The vocal fremitus is
normal, tactile fremitus is symmetrical. The lung expansion is normal. When percussed the sound is resonance. No adventitious sound heard upon
auscultation. Respiratory rate is 32 breaths per minute.
9. Cardiovascular: The rhythm is regular. PMI is located in the apical pulse. Heart rate is 77 beats per minute.
10. Breast and axilla: symmetrical with no signs of dimpling or retraction. Nipples are nearly equal bilaterally in size, no lesions, no abnormal discharges
and tenderness.
11. Abdomen: Skin has prominent discolorations of petechial rashes which is pinkish to reddish and white spots, the contour is round. Peristalsis is non-
visible. The color of his stool is black, it is solid and formed. The bowel sound is normo active and no bruits. When percussed the sound is tympany.
When palpated he doesn’t have any tenderness and when light palpation is done muscle guarding is absent. The liver is not palpable.

12. Extremities: there were present of .The client can resist force when asked to resist. Muscle strength is 5/5. The peripheral pulses are equal. Lymph
nodes are not palpable. The IV site is in his left arm.
13. Genitals: Not performed.
14. Rectum and anus: not performed.
15. Neurological/cranial nerves:
Olfactory: he is able to differentiate smell from that of an alcohol and perfume.
Optic: reacts on both sides.
Oculomotor: eyes move smoothly in a coordinated motion in all directions (the six cardinal fields).
Trochlear: Bilateral pupils constricts simultaneously when illuminated.
Trigeminal: temporal and masseter muscles contract bilaterally when chewing.
Abducens: pupils are equally rounded reactive to light and accommodation.
Facial nerve: patient is able to smile, frown, wrinkles forehead, shows teeth, puff out cheeks, purses lips, raises eyebrows, and closes eyes against
resistance in symetrical movement.
Vestibulocochlear: patient is able to hear whispered words from 1-2 feet.
Glossopharyngeal: has no difficulty in swallowing.
Vagus Nerve: the gag reflex is present.
Spinal Accessory nerve: there is symmetric, strong contraction of trapezius muscles when asked to shrug the shoulders against resistance. There is also
a strong contraction of sternocleidomastoid muscle on side opposite the turned face when turning the head against resistance.
Hypoglossal: can move tongue and can swallow without difficulties.
II.PERSONAL / SOCIAL HISTORY
a) Habits/Vices: watching television, eating.
b) Caffeine: none.
c) Smoking: none.
d) Alcohol: none.
e) Tea: None.
f) Drugs: none
g) Lifestyle: none.
h) Social Affiliation: not a member of any organization.
i) Rank in the family:
j) Travel: the patient did not travel within 6 months.
k) Educational attainment: currently under 2nd year high school.
III. ENVIRONMENTAL HISTORY
The patient lives in a barangay, near the farm fields and river, but far from their town proper. He lives with his family composed of his father, mother and
his 3 sibblings. Their house is concrete and bungalow type. Walking distance from their barangay health center at about 50 meters; they use tricycle or
jeepney as their transportation going to their town market and or hospitals.

Water source is from the water district and uses mineral water for drinking. They are using an open-pit privy for their garbages but most of the time, they
are throwing their wastes on the riverbank. Used bottles, plastics, and papers are recycled and being sold.
IV. ANATOMY AND PHYSIOLOGY

Circulatory System
The circulatory system in humans is a network of blood vessels through which the heart
pumps the blood and keeps the blood in circulation. The circulation system provides blood to
each cell in the body.
The circulatory system comprises of two sub systems – cardiovascular system and the
lymphatic system. The cardiovascular system consists of the heart, blood and the blood
vessels in the form of arteries and veins. The lymphatic system consists of the lymph vessels,
lymphatic nodes and lymph.
There are two categories of blood vessels – arteries and veins. The arteries carry the
oxygenated blood from the heart to the rest of the body where it distributes the oxygen and
nutrients. The veins carry the deoxygenated blood from the body organs back to the heart.
The heart pushes the deoxygenated blood to the lungs, where the blood exchanges the
carbon dioxide with fresh oxygen and is returned to the heart for recirculation to the body
organs. When the blood reaches the intestines, it collects nutrients for distribution and
discards the waste collected from the body cells to the intestines. The blood carries the
oxygen and the nutrients to the tissues of the body where it exchanges them with carbon
dioxide and waste from the cells. Waste like toxins are released into the kidneys.
Another important role of blood is to carry the white blood platelets that have the capacity to
fight germs and contain diseases to the infection areas. Therefore, blood helps the immune
system of the body.
The Heart
The heart is a special involuntary muscle called the cardiac muscle. Involuntary muscles keep
working on their own without our intervention or effort. The heart is divided into two sides
divided by the septum. Each side has two chambers – a ventricle and an atrium. The left side
of the heart is responsible for pumping the oxygenated blood from the lungs to the rest of the
body. The right side of the heart is responsible for bringing the deoxygenated blood back to
the lungs.

The heart keeps beating rhythmically using an electrical signal from the sinoatrial node located at the top of the heart. An electrocardiograph machine
can record these electric impulses to study the performance of the heart.
The heart is a very important part of the circulatory system. If a part of the blood is lost, one can survive as the blood can get regenerated very quickly.
However, any damage to the heart can be fatal. The heart is made up of involuntary cardiac muscles that keep the heart beating without any manual
intervention as long as it remains healthy.
Blood Vessels
The cardiovascular system part of the circulatory system is a closed network of blood vessels through which the blood keeps circulating due to the
action of the heart. The blood vessels that carry the oxygenated blood away from the heart to the body organs are called the arteries. The blood vessels
that collect the deoxygenated blood and bring it back to the heart are called the veins.
The blood vessels are thick near the heart and divide into smaller arteries and finally into capillaries that are only one cell layer thick. Just to compare,
the largest arteries called the aorta and the largest vein called the vena cava are each about an inch in diameter!
Lymph
When the blood carries the nutrition to the individual cells and collects waste, it forms the interstitial fluid between the cells of a tissue to transfer the
nutrients to the cells. The lymphatic system is a network of one way vessels that collect the interstitial fluid called lymph into the lymph vessels which
push the lymph by rhythmic contractions through several lymph nodes on the way into the subclavian veins where the lymph mixes back with the blood.
Blood
The blood is composed of fluid called plasma that contains red blood cells, white blood cells and platelets. The plasma carries the proteins, hormones
and minerals from one part of the body to the other. The red blood cells contain hemoglobin which helps to transport oxygen from the lungs to the rest of
the body parts. The white blood cells help to fight infections and diseases. The blood platelets help to clot after an injury thereby preventing an excess
loss of blood.
Blood performs many important functions within the body including:
 Supply of oxygen to tissues (bound to hemoglobin, which is carried in red cells)
 Supply of nutrients such as glucose, amino acids, and fatty acids (dissolved in the blood or bound to plasma proteins)
 Removal of waste such as carbon dioxide, urea, and lactic acid
 Immunological functions, including circulation of white blood cells, and detection of foreign material by antibodies
 Coagulation, which is one part of the body's self-repair mechanism
 Messenger functions, including the transport of hormones and the signaling of tissue damage
 Regulation of body pH (the normal pH of blood is in the range of 7.35 - 7.45)

 Regulation of core body temperature
 Hydraulic functions
V. INTRODUCTION
DENGUE is transmitted by the bite of an aedes mosquito infected with any one of the four dengue virus serotypes. It is a febrile illness that affects
infants, young children and adults with symptoms appearing 3-14 days after the infective bite.
Dengue is not transmitted directly from person to person and symptoms range from a mild fever, to incapacitating high fever, with severe headache, pain
behind the eyes, muscle and joint pain and rash. There is no vaccine or any specific medicine to treat dengue. People who have dengue fever should
rest, drink plenty of fluids and reduced the fever using paracetamol or see a doctor.
Dengue is widely distributed in tropical and sub tropical area of the world. In recent years however, it has spread to many countries with outbreaks even
in Europe and several countries recording an increasing number of imported cases.
Severe Dengue (formerly known as dengue hemorrhagic fever) is characterized by fever, abdominal pain, persisted vomiting, bleeding and breathing
difficulty and is potentially little complication, affecting mainly children. Early clinical diagnosis and careful clinical management by trained physicians and
nurses increase survival of patient.
DISEASE DENGUE HEMORRHAGIC FEVER
OTHER NAME: Breakbone Fever, H-fever, Dandy Fever
CAUSATIVE AGENT Dengue virus type 1,2,3 and 4
Chikungunya virus
Onyong-yong virus
Flavi virus
SOURCE OF INFECTION Female Aedes aegypti mosquito
CHARACTERISTIC:
Day Biting
Low flying
Stagnant Water
Urban
INCUBATION PERIOD 3-14 days
MODE OF TRANSMISSION Mosquito bite
SIGNS AND SYMPTOMS GRADE I
Fever, headache, joint pain, conjunctivitis, Herman’s sign, petechiae,
anorexia, abdominal pain, nausea and vomiting
GRADE II
Grade I + ecchymosis, purpura, epistaxis, melena
GRADE III
Grade II + shock

GRADE IV
Grade III + Profound shock
COMPLICATIONS Thrombocytopenia hypovolemic shock
DIAGNOSTIC TESTS 1. Tourniquet test / Rumple lead test / capillary fragility test
2. Platelet count
3. Viral isolation
4. Serologic test
MEDICAL MANAGEMENT 1. Boric acid / saline compress
2. Codeine, DO NOT GIVE ASPIRIN
3. Calamine lotion
4. BLOOD TRANSFUSION ***Fresh frozen Plasma
Exam Result Normal Values Interpretation

VII.
LABORATORY TEST
SEPTEMBER 08, 2013
COMPLETE BLOOD COUNT
RBC 5.4 4.69 – 6.13 X 10 12/L Normal
WBC 3.3 5 – 10 x 10 9/L
Decrease WBC indicates Leukocytosis can
be a sign of infection.
Segmenters 0.90 0.60 -0.70
Increase Segmenters indicates the
presence of an acute bacterial infection or
some inflammation going on inside the
body
Lymphocytes .34 0.20 – 0.40 Normal
Monocyte .10 .0 – 0.07 Increase: indicates presence of infection
Hgb 156 140 -180 Normal
Hct 0.51 0.40 – 0.54 Normal
Platelets Count 58 150 – 450 x 10 ^/ L
DECREASED: May indicate decreased
platelet production, increased platelet
destruction.

SEPTEMBER 09, 2013
RBC 5.5 4.69 – 6.13 X 10 12/L Normal
WBC 3.8 5 – 10 x 10 9/L

SEPTEMBER 10, 2013
Segmenters 0.45 0.60 -0.70 Normal
Lymphocytes .43 0.20 – 0.40
Increase Lymphocytes indicates can be
sign of infection.
Monocytes .12 .0 - .07 Increase: indicates presence of infection
Hgb 155 140 -180 Normal
Hct 0.43 0.40 – 0.54 Normal
DECREASED: May indicate decreased
destruction.

VIII. DRUG STUDY
RBC 4.9 4.69 – 6.13 X 10 12/L Normal
WBC 3.4 5 – 10 x 10 9/L
Segmenters 0.34 0.60 -0.70
Decrease Segmenters indicates the
presence of an acute bacterial infection or
some inflammation going on inside the
body
Lymphocytes .56 0.20 – 0.40
Increase Lymphocytes indicates sign of
infection.
Monocytes .10 .0 - .07 Increase: indicates presence of infection
Hgb 140 140 -180 Normal
Hct 0.46 0.40 – 0.54 Normal
Decreased: May indicate decreased
destruction.

GENERIC NAME: paracetamol
BRAND NAME: Biogesic
CLASSIFICATION: anti-pyretic
DOSAGE: 500mg 1 tablet PRN every 4hours for temperature 37.8°c and above
INDICATION: Fever
MECHANISM OF ACTION ADVERSE REACTIONS CONTRAINDICATION SIDE EFFECTS NURSING
CONSIDERATION
Drug may relieve fever
trough central action in the
hypothalamic heat-
regulating center
ʢ Leucopenia,
nuetropenia,
pancytopenia
Contraindicated in patients
hypersensitive to drug
 drowsiness - Instruct to remain on bed
after 30 minutes of giving
medication
GENERIC NAME: omeprazole

BRAND NAME:
CLASSIFICATION: antiulcer (proton pump inhibitor)
DOSAGE: 20mg IVP twice a day
INDICATIONS: for pathologic hypersecretory conditions
CONSIDERATION
Inhibits proton pump
activity by binding to
hydrogen-potassium
adenosine triphosphatase,
located at secretory
surface of gastric parietal
cells, to suppress gastric
acid secretion.
ʢ Erythema
multiforme,
pancreatitis,
hemolytic anemia,
fracture of bone,
liver failure,
anaphylaxis
ʢ Contraindicated in
patients
hypersensitive to
drug or its
components
 Headache,
Fatigue, Dizziness,
Light headedness
 Nausea, vomiting
- Promote comfort
measures and provide
adequate rest periods.
- advise to eat frequent
small feedings and avoid
spicy foods or acidic.
GENERIC NAME: diphenhydramine

BRAND NAME:
CLASSIFICATION: Antihistamine (ethanolamine)
DOSAGE: 10mg IVP now
INDICATIONS: for allergy symptoms
CONSIDERATION
Competes with histamine
for H₁-receptor sites.
ʢ Seizures,
thrombocytopenia,
agranulocytosis,
anaphylactic shock
ʢ Contraindicated in
patients
hypersensitive to
drug.
 Drowsiness,
Sedation,
Sleepiness
 dizziness
- let the patient take a rest
and promote comfort.
Ensure safety measures.
- Assist patient during
walking to restroom. Let
the patient take a rest.
GENERIC NAME: phytonadione

BRAND NAME: Vitamin K
CLASSIFICATIONS: nutritive agent/ anti-coagulant
DOSAGE: 10mg IVP now and every 8 hours x 3 doses
INDICATIONS: for clotting factor
CONSIDERATION
It is a cofactor for a
microsomal enzyme that
triggers the post-
translational carboxylation
of peptide-bound glutamic
acid residues into active
coagulation factor
ʢ anaphylaxis ʢ Hypersensitivity to
any component of
this medication
 Skin reaction - Stop the medication
immediately then refer to
the physician.
IX. NURSING CARE PLAN

FOCUS: abdominal pain
ASSESSMENT DIAGNOSIS SCIENTIFIC
BACKGROUND
OBJECTIVES INTERVENTION RATIONALE EVALUATION
Subjective:
 “mahapdi yong
tyan ko” as
verbalized
 Pain scale of
7/10
Objectives:
 Guarding
behavior
 facial grimace
 V/S as follows:
RR: 32bpm
PR: 102bpm
 Diaphoresis/cold
clammy skin
 pallor
Acute pain
related to
disease
process.
Body releases
anti
inflammatory
mediators
(cistatin, Kinins)
Vascular
response
Redness/heat
Absominal pain
After 30
minutes-1 hour of
nursing
intervention the
patient’s
complain of pain
will be controlled/
reduced from a
pain scale of
7/10 to 3/10
INDEPENDENT
Diagnostics:
 Assess for referred
pain, as
appropriate.
 Obtain client’s
assessment of pain
to including PQRST
of pain
 Monitor for vital
sign every 4 hours,
including skin color
and temperature
 Observe non verbal
cues and pain
behaviors and
other objective,
defining the
characteristics as
noted.
Therapeutics:
 Provide comfort
measures(prepositi
oning, quite
environment,
ventilation)
Educative:
 Encourage
adequate rest
periods.
 To help determine
for possibility of
underlying condition
or organ dysfunction
requiring treatment.
 To rule out
worsening of
underlying condition
of development of
complication
 Which are usually
altered in acute
pain.
 Observation may not
be congruent with
verbal reports or
maybe only indicator
present when client
is unable to
verbalize
 To promote non
pharmacological
pain management
 To prevent fatigue.
Goal partially met.
Patient’s complains
of pain reduced
from pain scale of
7/10 to 4/10.

 Instruct and
encourage use of
relaxation
techniques such
as DBE
 Instruct to avoid
acidic food
DEPENDENT:
 Administer
medication as
prescribed:
omeprazole 20mg
IVP twice a day
 To assist client to
explore methods for
alleviation or control
of pain
 This may trigger
abdominal pain
 Inhibits proton pump
activity by binding to
hydrogen-potassium
adenosine
triphosphatase, to
suppress gastric
acid secretion.

FOCUS: itchy skin
BACKGROUND
Subjective:
“Nangangati ako”
as verbalized
Objectives:
 Redness of
the skin
 Skin rashes all
over the body
Impaired skin
integrity
related to
presence of
petechial
rashes.
Cellular direct
destruction and
infection of red
bone marrow
precursor cells as
well as
immunological
shortened platelet
survival causing
platelet lyses
Thrombocytope
nia
Increase number
and size of the
pores in the
capillaries which
leads to a
leakage of fluid
from the blood to
the interstitial fluid
(capillary
leakage) of the
different organs
and skin
Petechial rash
Short term
objective:
 Within 2hours
of nursing
intervention,
patient will
demonstrate
behavior in
preventing
skin
impairment
INDEPENDENT
Diagnostics:
 Palpate skin
lesions for
consistency,
texture & hydration.
Therapeutics:
 Provide skin
hygiene through
sponge bathing &
changing regularly
 Keep bed clothes
dry, use non-
irritating materials,
& keep bed
wrinkled free
Educative:
 Encourage
reposition schedule
for client
 Provide information
to the client about
the importance of
regular observation
& effective skin
care
DEPENDENT:
 Administer
medication as
prescribed:
diphenhydramine
10 mg IVP.
 To assess extent of
involvement of skin
impairment.
 To maintain skin
integrity at optimal
level.
 To prevent friction
that may cause
irritation of the skin
 To avoid lesions,
scratching of skin &
harboring of
microorganism.
 To promote
wellness by gaining
knowledge on
treatment/ therapy
 Competes with
histamine for H₁-
receptor sites.
Goal met. The
patient was able to
demonstrate
behavior of
preventing skin
impairment.

FOCUS: signs of bleeding
BACKGROUND
Subjective:
“ maitim yung tae
Risk for
shock
Dengue virus
goes into the
After 8 hour shift of
nursing intervention
INDEPENDENT
Diagnostics:
Goal partially met.
The patient was

ko “ as
verbalized
Objective:
 Decrease
platelet
count: 57 x
10 g/L
 Petechial
rash all over
the body
related to
bleeding
circulation
Infects cells and
generate
cellular
response
Initiates
destruction of
platelets
Increase
potential for
hemorrhage
Stimulates
intense
inflammatory
response
Release of anti
inflammatory
mediators
Vascular
response
Epistaxis,
melena,
abdominal pain,
patient will report
absence of melena.
 Monitor for persistent or
heavy fluid loss,including
vomiting,epistaxis,melena
 Assess v/s and tissue
and organ perfusion
including state of
consciousness and
mentation every 1-4
hours and watch out for
any signs of bleeding.
 Review laboratory data
such as CBC and
differential count; Platelet
numbers; other
coagulation factors.
Educative:
 Instruct to avoid dark
colored foods(for
monitoring of melena)
and acidic foods.
DEPENDENT:
 Administer IVF of D5LRS
x 1 liter and regulate to
30-31 gtts/min, as
ordered.
 Administer medication as
indicated:
 phytonadione
10mg IVP
now and
every 8
hours x 3
doses;
 To assess
causative/contrib
uting factor
 To note for
changes
associated with
shock stage.
 To identify
potential sources
of shock and
degree of organ
involvement.
 Dark colored
foods may
interfere with the
result for old
blood.
 To rapidly restore
or sustain
circulating
volume,
electrolyte
balance, and
prevent shock
state.
 It is a cofactor for
a microsomal
enzyme that
triggers the post-
translational
carboxylation of
able to display
absence of
melena but still
had low platelet
count.

petechiae peptide-bound
glutamic acid
residues into
active
coagulation
factor.
FOCUS: lack of information
BACKGROUND
Subjective: Knowledge Deficiency of Short term INDEPENDENT Goal met. The

“ 6 days nako
nilalagnat bago
paconfine, kasi di
namin alam na
dengue na pala
ito, as verbalized.
Objectives:
 Frequently
asks questions
regarding the
disease.
deficit related
to lack of
information of
the Disease.
cognitive
information
related to lack of
information thus
development of
preventable
complications.
objective:
After an hour or
two of health
teaching, the
patient will be
able to verbalize
understanding
regarding on his
condition,
disease process
and treatment.
Diagnostics:
 Ascertain level of
knowledge,
including
anticipatory needs.
 Determine client’s
ability, readiness,
and barriers to
learning.
Therapeutics:
 Provide information
relevant only to the
problem.
 Provide access
information.
Educative:
 Discuss client’s
perception of need.
Relate information
to client’s personal
desires, needs,
values and beliefs.
 Explain the disease
process ( signs and
symptoms ),
identify possible
causes. Describe
the condition of the
client
 To assess
readiness to learn.
 Individually may not
be physically,
emotionally or
mentally capable at
this time.
 To provide
information and
prevent overload.
 To answer questions
and validate
information.
 So that client feels
competent and
respected.
 Increase knowledge
and reduce anxiety
patient was able to
verbalize
understanding
regarding on his
condition, the
disease process
and treatment.
FOCUS: Anxiety
ASSESSMENT DIAGNOSIS SCIENTIFIC OBJECTIVES INTERVENTION RATIONALE EVALUATION

BACKGROUND
Subjective:
“Nakaka stress na
dito sa ospital,” as
verbalized
Objectives:
 Worries about
hospitalization
 Increase RR
32bpm
 Increase
tension
 Restlessness
Anxiety
related to
stress to
hospitalization
.
Vague uneasy
feeling of
discomfort or
dread
accompanied by
an autonomic
response.
Short term
objective:
 After 2 hours
of nursing
intervention
the patient will
be able to
verbalized
reduce feeling
of anxiety
INDEPENDENT
Diagnostics:
 Help the client to
determine the
source of anxiety.
Help the client to
determine the level
of anxiety.
Therapeutics:
 Provide support,
stay with the client
speak slowly and
calm and convey a
sense of caring and
empathy.
Educative:
 Encourage client to
verbalize feeling
and express
emotions.
 These actions will
help the client to
establish realistic
understanding of
the nature and
cause of anxiety.
Once stress is
accurately
understood and the
client can readily
identify strategies
for coping.
 Providing reassuring
presence decreases
the client stress of
alones and support
the client’s coping.
 Sharing concerns
and expressing
emotions can
decrease the clients
feeling being alone
or overwhelmed by
stressful situation.
Goal met. The
patient was able to
verbalized reduced
feeling of anxiety
X. LIST OF IDENTIFIED PROBLEMS
 Acute pain related to disease process.
 Risk for impaired skin integrity related to presence of petechial rashes.

 Risk for shock related to bleeding.
 Knowledge deficit related to lack of information
 Anxiety related to stress to hospitalization
 Disturbed body image related to presence of rashes all over the body
 Risk for imbalanced Nutrition Less Than Body Requirements related to inadequate nutritional intake due to decreased appetite
XI. ONGOING APPRAISAL
September 10, 2013
> Received lying on bed with an ongoing IVF of D5LRS 1li at 650 cc level regulated at 30-31 gtts/min infused at the left arm. Conscious and
coherent, afebrile and can do Activities of daily living without assistance. TPR every 4 hours and recorded. All due medications are given.
September 11, 2013
> Received sitting on chair with an ongoing IVF of D5LRS 1 li at 200cc level, infusing well at the left arm. Conscious and coherent, afebrile and
can move without assistance. Still under monitoring. TPR every 4 hours and recorded. Due medications are given. Endorsed for continuity of care.
XII. DISCHARGE PLAN (HEALTH TEACHING)
Diet:
> Encourage nutritious foods like vegetables, meat and fruits.
Medications:
> Give paracetamol in case the temperatures increases and avoid giving aspirin when dengue fever is suspected.
Outpatient follow-up
> Follow-up check-up after 1 week with the doctor to identify and prevent reoccurrence of signs and symptoms of dengue
Treatment:
> Increased oral fluid intake.
Health Teaching:
> D- discuss the possible source of infection of the disease.
> E- educate the family/patient on how to eliminate those vectors.
> N- Never stocked water in a container without cover.
> G- Gallon, container and tires must have proper way of disposal.
> U- Use insecticides to kill or reduce the population of mosquito at home.
> E- Encourage the family of the patient to clean the surroundings to destroy the breeding places of mosquito.
 The best way to prevent dengue fever is to take special precautions to avoid contact with mosquitoes.
 Eliminate vector by:

 Changing water and scrubbing sides of lower vases once a week
 Destroy breeding places of mosquito by cleaning surroundings
 Proper disposal of rubber tires, empty bottles and cans
 Keep water containers covered
Because Aedes mosquitoes usually bite during the day, be sure to use precautions
especially during early morning hours before daybreak and in the late afternoon before dark.
Other precautions include:
 When outdoors in an area where dengue fever has been found
 Use a mosquito repellant containing DEET, picaridin, or oil of lemon eucalyptus
 Dress in protective clothing-long-sleeved shirts, long pants, socks, and shoes
 Keeping unscreened windows and doors closed
 Keeping window and door screens repaired
 Use of mosquito nets

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