Capitol Medical Center CollegeCollege of Nursing

A Case StudyA Case Study

DENGUE FEVERDENGUE FEVER

Presented to:Presented to:Mrs. Glenda FadriMrs. Glenda Fadri

In Partial Fulfilment of the RequirementsIn Partial Fulfilment of the Requirements

For the Degree ofFor the Degree of

Bachelor of Science in NursingBachelor of Science in Nursing

TANCIOCO, MARK ANDREWTANCIOCO, MARK ANDREWTANDOC, JOHANNA ELAINETANDOC, JOHANNA ELAINE

TIBANGEN, DOLLY ANNETIBANGEN, DOLLY ANNETIMPUG, MARIA ROSANNATIMPUG, MARIA ROSANNA

TINDOY, NEIL JASONTINDOY, NEIL JASON

11stst Semester SY 2009-2010 Semester SY 2009-2010

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 death2. Moderate>with high fever but less hemorrhage, no shock present3. 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 testGrade 2:>signs and symptoms of Grade 1: plus>presence of spontaneous bleeding: mucocutaneous, gastrointestinalGrade 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 confusionGrade 4:>signs and symptoms of Grade 3, declared shock, massive bleeding, pulse less and arterial blood Pressure = 1 mmhg (Dengue Syndrome/DS)

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.II. Objectives

a. GeneralThe purpose of this case presentation is to provide and broaden the knowledge

of the students as well as the readers regarding dengue fever, also intends to help patient promote health and medical understanding of such condition through the application of the nursing skills. This study will show the risk factors, manifestations, and complications of the disease which will contribute and equip student-nurse who will be handling the same condition in the future with enough knowledge, competitive skills and right attitude.

b. SpecificKnowledge

The researchers would like to obtain a comprehensive knowledge regarding

abnormal uterine bleeding through identifying the pathophysiology, signs and

symptoms, laboratory examinations, diagnostics procedures and treatment.

Skills

The researchers would like to enhance nursing skills that would make competitive

and knowledgeable student nurses by applying proper nursing intervention and care to

the patient having abnormal uterine bleeding, providing an appropriate health teaching

to the patient and right medication as well.

Attitude

The researchers would like to establish a positive attitude in making this case

presentation by having an open mind to the importance of abnormal uterine bleeding,

establish rapport and trusting relationship with patient’s significant others, in every

intervention you do and to understand the importance of teamwork.

III. Patient’s Dataa. Name: J. R. L.b. Address: Quezon Cityc. Age: 16d. Sex: Fe. Civil Status: Singlef. Religion: Roman Catholicg. Birthday: June 13, 1993h. Birth Place: Quezon Cityi. Room Number: 542 - Bj. Hospital Number: 331300k. Attending Physician: Dr. L. M. Naidasl. Admission Diagnosis: Systematic viral illness turn out as dengue feverm. Chief Complaint: Fever

IV. Medical History.

a. History of Present Illness:

1 day prior to admission, patient developed fever at 39.7 C with associated headache. She was given paracetamol which gave her temporary relief.

On the day of admission, there was persistent fever hence admitted at Emergency Room and was subsequent admitted.

b. Past Medical History:

Childhood illness Asthma, feverChildhood immunization AllAllergies No known allergiesAccidents or injuries NoneHospitalization AsthmaMedications nebulization

c. Family Medical History:Asthma - (+) mother side

Family Member Health Related ProblemFather NoneMother AsthmaBrother Asthma

d. Social History:

Birthplace Quezon cityEducation 4th year High SchoolOccupation StudentEthnic lineage NONEMarital Status SingleHabits Diet Mixed Foods

Sleep Sleep for atleast 8 hours a day,but at present only 6 hours.

Hobbies Texting, watching tv, internet

V. Theoretical Framework

Nightingale’s philosophy primarily focuses on the environment, and the patient’s response to their environment. Nightingale’s theory is founded on the belief that a patient’s environment could be altered in order “to allow nature to act on the patient” . The nurse and health are also important components in Nightingale’s theory. Environment, person, health, and nursing— the foundation of Nightingale’s theoretical framework. “I use the word nursing for want of a better word. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet—all at the least expense of vital power to the patient.” Florence Nightingale

VI. Physical Assessment

BODY PART FINDINGS INTERPRETATION

◊ HEADSkull

Scalp/ Hair

◊ proportional to the size of the body, round, with prominences in the frontal area anteriorly & the occipital area posteriorly, symmetrical in all planes, gently curved.

◊ scalp is white, clean, free from

◊ Normal

◊ Normal

Face

Eyes/ Vision

Ears/ Hearing

Nose

Mouth/ Lips

masses, lumps, nits, dandruff & lesions, with no areas of tenderness upon palpation; hair is black, evenly distributed & covers the whole scalp, thick & shiny.

◊ oblong shaped, symmetrical, smooth & no involuntary muscle movements.

◊ eyes are parallel & evenly placed, symmetrical, no protruding, with scant amount of secretions, both eyes black & clear; sclera is white & clear; eyebrows are black, symmetrical, thick, can raise both symmetrically & without difficulty, evenly distributed & parallel with each other; eyelashes are evenly distributed & turned outward; upper eyelids cover a small portion of the iris, cornea & the sclera when the eyes are open, when the eyes are closed the lids meet completely, symmetrical & the color is the same as the surrounding skin; lid margins are clear, without scaling or secretions; lower palpebral conjunctiva are shiny, moist, transparent & salmon pink in color; iris are proportional to the size of theeye, round & symmetrical; pupils are from pinpoint to almost the size of the iris, round, symmetrical, constricts with increasing light & accommodation; able to move eyes in full range ofdirection.

◊ ears are parallel, symmetrical,proportional to the size of the head, bean-shaped, helix is in line with the outer canthus of the eye, skin is the same color as the surrounding area & clean; ear canal is pinkish, clean, with scant amount of cerumen & a few cilia; able to hear whisper spoken 2 feet away; 2 piercing are found in left ear and 1

◊ Normal

◊ Normal

◊ Normal

◊ Normal

◊ Normal

◊ NECK

◊ THORAX &LUNGSHEART

◊ BREAST

◊ ABDOMEN

◊ LOWEREXTREMITIES

piercing in right ear

◊ nose is in midline, symmetrical, patent; internal nares are clean, dark pink with few cilia

◊ lips are pinkish, symmetrical, lip margin is welldefined, smooth & moist; gums are pinkish, smooth, moist, no swelling, no retraction, no discharge; 32 teeth are present, aligned, with no dental caries; tongue is pinkish, slightly rough on top, smooth along the lateral margins, moist, shiny & freely movable; cheeks are pinkish, moist & smooth; frenulum is in midline, straight & thin; soft palate is pinkish, smooth & moist; hard palate is slightly pinkish; uvula is at the center, symmetrical & freely movable

◊ proportional to the size of the body & head, symmetrical & straight, no palpable lumps, masses or areas of tenderness

◊ chest contour is symmetrical, spine is straight, no lumps, no masses, no tender areas, with clear breath sounds

◊ no abnormal pulsations, pulsations are palpable & visible in apical area

◊ symmetrical, pinkish nipples, no cracks & discharges, uniform in skin color, smooth & intact, no lumps, masses & tenderness

◊ abdominal skin is unblemished, no scars, color is uniform with the body color, abdomen is rounded with symmetric movements caused by respiration; umbilicus is concave

◊ symmetrical, with visible veins, fine hair evenly

◊ Normal

◊ Normal

◊ Normal

◊ Normal

◊ Normal

◊ Normal

◊ Normal

distributed, warm, dry & elastic upon palpation, with area of tenderness on the left arm; palms are pinkish, warm, soft & elastic; nails are transparent, smooth & convex with light pink nail beds & white translucent tips; 5 fingers in each hand; both shoulders, arms, elbows, hands & wrists can be moved in different range of motion with relative ease; c marks of petechial rashes

◊ skin is smooth, fine hair is evenly distributed, absence of varicose veins, muscles symmetrical, length symmetrical, 5 toes in each foot, sole & dorsal surface is smooth with pink nail beds & white translucent tips; both legs, knees, ankles, & toes can be moved in different range of motion with relative ease; scar on both patellar; c non pitting bipedal edema

VII. Patterns of Functioning

PATTERN BEFORE PRESENT

1. Health perception, health management

The patient perceived her health in good condition. She manages her health by practicing proper hygiene and eating nutritious foods.

She rely her present condition with the help of the therapeutic personnel and by following the prescribed medications.

2. nutritional metabolic management

Prior to confinement, she eats moderately. She often eats fish, meat and vegetables. She admits that she drinks plenty of water and gets herself well-hydrated.

During hospitalization, the patient is on diet for age; no dark colored foods.

3. elimination pattern

Before her confinement, she usually urinates for at least 5 times a day and defecates regularly..

During her confinement, she seldom urinate and defecate.

4. activity, leisure, and

During her leisure time before confinement, she usually surf the internet,

Her activities in the hospital are eating

recreation pattern

watch television and text her friends.

healthy foods and her personal hygiene.

5. sleep and rest pattern

Before her confinement, she doesn’t have trouble going to sleep.

During her confinement, she was able to rest and have enough sleep as well.

6. cognitive-perceptual pattern

She has a good memory and reasoning skills. She can easily comprehend on things.

She responds clearly and well understood. She responds appropriately to verbal and physical stimuli and obey simple commands.

7. self-perception/ self-concept pattern

She describes herself as a typical type of student and person.

8. role relationship

She has a close relationship with her family. She also is a responsible student.

The patient’s family is supportive to the patient. She is happy with their presence and support.

9. sexuality/ reproductive pattern

She doesn’t have a boyfriend yet.

10. coping and stress tolerance

She does not fully identify her situations having stress.

She shares her problems to her family who always supports her.

11. values-belief pattern

Patient is a Roman Catholic. she has a strong faith to God and goes to mass every Sunday with her family.

During her confinement, she always pray to God.

VIII. Laboratory and Diagnostic ExaminationsOct. 6, 2009

TEST RESULT REFERENCEHemoglobin 145 120-150Hematocrit 0.43 0.37-0.45Erythrocytes 4.83 4.0-5.0MCV 88.40 80-96MCH 30.00 27-33MCHC 34.00 3-36Platelets 225 150-440

Total WBC 3.2 5.0-10.0Neutrophils 0.58 0.55-0.65Lymphocytes 0.34 0.25-0.40Monocytes 0.05 0.02-0.06Eosinophils 0.00 0.1-0.50Stabs 0.03 0.01-0.03

Oct. 7, 2007

TEST RESULT REFERENCEHemoglobin 138 120-150Hematocrit 0.41 0.37-0.45Erythrocytes 4.54 4.0-5.0MCV 89.40 80-96MCH 30.40 27-33MCHC 34.00 3-36Platelets 280 150-440Total WBC L 2.2 5.0-10.0Neutrophils 0.49 0.55-0.65Lymphocytes 0.43 0.25-0.40Monocytes 0.02 0.02-0.06Eosinophils 0.03 0.1-0.50Stabs 0.03

w/ atypical lymph.0.01-0.03

Oct. 8, 2009

TEST RESULT REFERENCEHemoglobin 140 120-150Hematocrit 0.41 0.37-0.45Erythrocytes 4.65 4.0-5.0MCV 88.60 80-96MCH 30.10 27-33MCHC 34.00 3-36Platelets 230 150-440Total WBC L 2.7 5.0-10.0Neutrophils 0.53 0.55-0.65Lymphocytes 0.41 0.25-0.40Monocytes 0.02 0.02-0.06Eosinophils 0.04 0.1-0.50Stabs 0.00

w/ atypical lymph.0.01-0.03

IX. Anatomy and Physiology

The lymphatic system in vertebrates is a network of conduits that carry a clear fluid called lymph. It also includes the lymphoid tissue through which the lymph travels. Lymphoid tissue is found in many organs, particularly the lymph nodes, and in the lymphoid follicles associated with the digestive system such as the tonsils. The system also includes all the structures dedicated to the circulation and production of lymphocytes, which includes the spleen, thymus, bone marrow and the lymphoid tissue associated with the digestive system.[1]

The lymphatic system as we know it today was first described independently by Olaus Rudbeck and Thomas Bartholin.

The blood does not directly come in contact with the parenchymal cells and tissues in the body, but constituents of the blood first exit the microvascular exchange blood vessels to become interstitial fluid, which comes into contact with the parenchymal cells of the body. Lymph is the fluid that is formed when interstitial fluid enters the initial lymphatic vessels of the

lymphatic system. The lymph is then moved along the lymphatic vessel network by either intrinsic contractions of the lymphatic vessels or by extrinsic compression of the lymphatic vessels via external tissue forces (e.g. the contractions of skeletal muscles).

The lymphatic system has three interrelated functions: it is responsible for the removal of interstitial fluid from tissues; it absorbs and transports fatty acids and fats as chyle to the circulatory system; and it transports immune cells to and from the lymph nodes. The lymph transports antigen presenting cells (APCs), such as dendritic cells, to the lymph nodes where an immune response is stimulated. The lymph also carries lymphocytes from the efferent lymphatics exiting the lymph nodes.

The study of lymphatic drainage of various organs is important in diagnosis, prognosis, and treatment of cancer. The lymphatic system, because of its physical proximity to many tissues of the body, is responsible for carrying cancerous cells between the various parts of the body in a process called metastasis. The intervening lymph nodes can trap the cancer cells. If they are not successful in destroying the cancer cells the nodes may become sites of secondary tumors.

Diseases and other problems of the lymphatic system can cause swelling and other symptoms. Problems with the system can impair the body's ability to fight infections.

Organization

The lymphatic system can be broadly divided into the conducting system and the lymphoid tissue.

The conducting system carries the lymph and consists of tubular vessels that include the lymph capillaries, the lymph vessels, and the right and left thoracic ducts.

The lymphoid tissue is primarily involved in immune responses and consists of lymphocytes and other white blood cells enmeshed in connective tissue through which the lymph passes. Regions of the lymphoid tissue that are densely packed with lymphocytes are known as lymphoid follicles. Lymphoid tissue can either be structurally well organized as lymph nodes or may consist of loosely organized lymphoid follicles known as the [[mucosa-associated lymphoid tissue](MALT)].

Formation of lymph

Blood supplies nutrients and important metabolites to the tissues, and collects back the waste products that they produce, which requires exchange of respective constituents between the blood and tissues. This exchange is not direct, however, and is effected through an intermediary called interstitial fluid or tissue fluid that the blood forms.

Interstitial fluid (ISF) is the fluid that occupies the spaces between the cells and acts as their immediate environment. As the blood and the surrounding cells continually add and remove substances from the ISF, its composition keeps on changing. Water and solutes can freely pass (diffuse) between the ISF and blood, and thus both are in dynamic equilibrium with each other; exchange between the two fluids occurs across the walls of small blood vessels called capillaries.

ISF forms at the arterial (coming from the heart) end of the capillaries because of higher pressure of blood, and most of it returns to its venous ends and venules; the rest (10—20%) enters the lymph capillaries as lymph. Thus, lymph when formed is a watery clear liquid with the same composition as the ISF. As it flows through the lymph nodes, however, it comes in contact with blood and tends to accumulate more cells (particularly lymphocytes) and proteins.

The two primary lymph systems are the thymus gland and the bone marrow, where the immune cells form or mature. The secondary lymph system is made up of encapsulated and unencapsulated diffuse lymphoid tissue. The encapsulated tissue includes the spleen and the lymph nodes. The unencapsulated tissue includes the gut-associated lymphoid tissues and the tonsils.

Lymphoid tissue

Lymphoid tissue associated with the lymphatic system is concerned with immune functions in defending the body against the infections and spread of tumors. It consists of connective tissue with various types of white blood cells enmeshed in it, most numerous being the lymphocytes.

T The lymphoid tissue may be primary, secondary, or tertiary depending upon the stage of lymphocyte development and maturation it is involved in. Primary (central) lymphoid tissues serve to generate mature virgin lymphocytes from immature progenitor cells. Secondary (peripheral) lymphoid tissues provide a place where lymphocytes can talk to each other; an environment for antigen focusing, where lymphocytes can 'study' an antigen and sharpen up the immune response by clonal expansion and affinity maturation; and provide a home for lymphocytes, where they can be available when they are needed.

The thymus and the bone marrow constitute the primary lymphoid tissues involved in the production and early selection of lymphocytes. Secondary lymphoid tissue provides the environment for the foreign or altered native molecules (antigens) to interact with the lymphocytes. It is exemplified by the lymph nodes, and the lymphoid follicles in tonsils, Peyer's patches, spleen, adenoids, skin, etc. that are associated with the mucosa-associated lymphoid tissue (MALT). The tertiary lymphoid tissue typically contains far fewer lymphocytes, and assumes an immune role only when challenged with antigens that result in inflammation. It achieves this by importing the lymphocytes from blood and lymph.

Lymph nodes

A lymph node showing afferent and efferent lymphatic vessels

A lymph node is an organized collection of lymphoid tissue, through which the lymph passes on its way to returning to the blood. Lymph nodes are located at intervals along the lymphatic

system. Several afferent lymph vessels bring in lymph, which percolates through the substance of the lymph node, and is drained out by an efferent lymph vessel.

The substance of a lymph node consists of lymphoid follicles in the outer portion called the "cortex", which contains the lymphoid follicles, and an inner portion called "medulla", which is surrounded by the cortex on all sides except for a portion known as the "hilum". The hilum presents as a depression on the surface of the lymph node, which makes the otherwise spherical or ovoid lymph node bean-shaped. The efferent lymph vessel directly emerges from the lymph node here. The arteries and veins supplying the lymph node with blood enter and exit through the hilum.

Lymph follicles are a dense collection of lymphocytes, the number, size and configuration of which change in accordance with the functional state of the lymph node. For example, the

follicles expand significantly upon encountering a foreign antigen. The selection of B cells occurs in the germinal center of the lymph nodes.

Lymph nodes are particularly numerous in the mediastinum in the chest, neck, pelvis, axilla (armpit), inguinal (groin) region, and in association with the blood vessels of the intestines.

Lymphaticslymphatic system

Tubular vessels transport back lymph to the blood ultimately replacing the volume lost from the blood during the formation of the interstitial fluid. These channels are the lymphatic channels or simply called lymphatics.

General structure of Lymphatics

The general structure of lymphatics is based on that of blood vessels. There is an inner lining of single flattened cells composed of a type of epithelium that is called endothelium, and the cells are called endothelial cells. This layer functions to mechanically transport fluid and since the basement membrane on which it rests is discontinuous; it leaks easily. The next layer is that of smooth muscles that are arranged in a circular fashion around the endothelium, which by shortening (contracting) or relaxing alter the diameter (caliber) of the lumen. The outermost layer is the adventitia that consists of fibrous tissue. The general structure described here is seen only in larger lymphatics; smaller lymphatics have fewer layers. The smallest vessels (lymphatic or lymph capillaries) lack both the muscular layer and the outer adventitia. As they proceed forward and in their course are joined by other capillaries, they grow larger and first take on an adventitia, and then smooth muscles.

The whole lymphatic conducting system broadly consists of two types of channels—the initial lymphatics, the prelymphatics or lymph capillaries that specialize in collection of the lymph from the ISF, and the larger lymph vessels that propel the lymph forward.

Unlike the cardiovascular system, the lymphatic system is not closed and has no central pump. Lymph movement occurs despite low pressure due to peristalsis (propulsion of the lymph due to alternate contraction and relaxation of smooth muscle), valves, and compression during contraction of adjacent skeletal muscle and arterial pulsation.

Lymph capillaries

Propulsion of lymph through lymph vessel

The lymphatic circulation begins with blind ending (closed at one end) highly permeable superficial lymph capillaries, formed by endothelial cells with button-like junctions between them that allow fluid to pass through them when the interstitial pressure is sufficiently high. These button-like junctions consist of protein filaments like platelet endothelial cell adhesion molecule-1 or (PECAM-1). A valve system in place here prevents the absorbed lymph from leaking back into the ISF. There is another system of semilunar (semi=half; lunar=related to the Moon) valves that prevents back-flow of lymph along the lumen of the vessel. Lymph capillaries have many interconnections (anastomoses) between them and form a very fine network.

Rhythmic contraction of the vessel walls through movements may also help draw fluid into the smallest lymphatic vessels, capillaries. If tissue fluid builds up the tissue will swell; this is called edema. As the circular path through the body's system continues, the fluid is then transported to progressively larger lymphatic vessels culminating in the right lymphatic duct (for lymph from the right upper body) and the thoracic duct (for the rest of the body); both ducts drain into the circulatory system at the right and left subclavian veins. The system collaborates with white blood cells in lymph nodes to protect the body from being infected by cancer cells, fungi, viruses or bacteria. This is known as a secondary circulatory system.

Lymph vessels

The lymph capillaries drain the lymph to larger contractile lymphatics, which have valves as well as smooth muscle walls. These are called the collecting lymphatics. As the collecting lymph vessel accumulates lymph from more and more lymph capillaries in its course, it becomes larger and is called the afferent lymph vessel as it enters a lymph node. Here the lymph percolates through the lymph node tissue and is removed by the efferent lymph vessel. An efferent lymph vessel may directly drain into one of the (right or thoracic) lymph ducts, or may empty into another lymph node as its afferent lymph vessel. Both the lymph ducts return the lymph to the blood stream by emptying into the subclavian veins

The functional unit of a lymph vessel is known as a lymphangion, which is the segment between two valves. Since it is contractile, depending upon the ratio of its length to its radius, it can act either like a contractile chamber propelling the fluid ahead, or as a resistance vessel tending to stop the lymph in its place.

X. PathophysiologyXI. Drug study

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

---- 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.

---- Drug-Herd

- Watercress: may inhibit oxidative metabolism of acetaminophen. Discourage use together.

---- Drug-Food

- Caffeine: may enhance analgesic effects of acetaminophen. Products may combine caffeine and acetaminophen for therapeutic advantage.

---- Drug-Lifestyle

- Alcohol use: may increase risk of hepatic damage. Discourage use together.

XII. Nursing Care Plan

XIII. Day to day prognosis

Patient J.R.L. was admitted chief complaint of fever and was admitted at room 542-B on the 5th day of October. She was endorsed to student nurse on her 4th day of admission.

DAY 1:

Received patient awake on bed with an on going IVF D5NM I liter at 400cc level and was regulated at 110cc/hour. Patient was conscious, coherent and ambulatory.

Patient was on special diet which is DIET FOR AGE; NO DARK COLORED FOODS as ordered by her attending physician, Dr. Naidas.

Morning care was rendered and patient was happy for the care that was given to her.

Vital signs was taken and was recorded with a result as follows: BP-110/70, PR-103bpm, RR-20 and an afebrile temperature which is 36C.

Above IVF was consumed and removed at 10am and was replaced with the same IVF as ordered by AP.

A good body movement was observed and patient has seen happiness as if she wasn’t admitted at the hospital.

According to the patient, there was a negative bowel movement since the first day of admission that’s why increased oral fluid intake was advised to the patient.

All needs were given and patient was endorsed to the next shift.

DAY 2:

Received patient asleep on bed with an on going IVF D5NM I liter at full cc level and was regulated at 110cc/hour. Patient was conscious, coherent and ambulatory.

Patient was on special diet which is DIET FOR AGE; NO DARK COLORED FOODS as ordered by her attending physician, Dr. Naidas.

Vital signs was taken and was recorded with a result as follows: BP-110/80, PR-80bpm, RR-20 and an afebrile temperature which is 36C.

Morning care was rendered and patient was happy for the care that was given to her.

Until this shift, patient was still negative for bowel movement and still encouraged to increase oral fluid intake because poor fluid intake was observed.

Patient was still in recovery and was given health teachings for her to practice in their house or wherever she may go.

All patient’s needs were given and was endorsed to the next shift.

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