Saint Michael’s College of Laguna

School of Nursing & midwifery

Old National Road, Platero Biñan Laguna

In partial fulfillment in our Related Learning Experience

A case study on

Dengue
Hemorrhagic Fever

Ms. Edith Vizarra RN, Man

Clinical Instructor

Submitted By
AÑABIEZA, Babyrlene P.

Date of Rotation
July 19-21, 26-28, 2010
INTRODUCTION

GOAL

• To be knowledgeable about the nature of Dengue Fever Syndrome,

management and treatment to be able to render effective nursing
care to the client.

• To be knowledgeable on how to prevent the disease

• To know the treatment and how to apply it

• To know the diagnostic exam

We live in our world today where everything seems to be in a fast face.

As it is, we cannot deny that things change over or in a certain period of

time. New technologies were being invented, clothes for fashion, jewelries,
luxuries mode of entertainment, etc. It’s just like having a new mode of
socialization, cultures, beliefs, perceptions, adaptation to life and environment.
With all of these, one aspect of human being which are greatly affected and the
one which we have to be most concern of would be in the side of our heath and
well being.

In the Philippines there are many diseases illness arising because of

environmental changes that may be caused by human activities and
geographical conditions. It is considered as one of the tropical country and so
disease can spread through out the country.

One example of these is disease is what we called Dengue Fever and

dengue Hemorrhagic Fever (DHF). It is considered as one of the acute febrile
diseases caused by one of the four closely related virus serotype of the genus
flavivirus. It can be transmitted by Aedes Aegypti mosquito to humans usually
attacking during the day. One will experience onset of fever, severe headaches,
muscle and joint pains which will give name to Breakbone Fever or Bonecrusher.
There are also rashes characterized by bright red petechaie commonly seen on
the lowers limbs and on the chest. There may also be gastritis associated to
abdominal pain, nausea, vomiting, or diarrhea. Proper attention of health care
provider should be given including good assessment, early detection or diagnosis
and medications which are essential for total interference of prevention.

Causative agent
It is caused by four antigenically related but distinct serotypes of the dengue virus DEN-
1, DEN-2, DEN-3 and DEN-4.

Mode of transmission
A strain of Arbovirus caused Dengue Hemorrhagic Fever and transmitted by the Aedes
aegypti mosquito.

Characteristics of an Aedes aegypti mosquito:

1. Daybiting
2. Low-flying
4. In urban area

Incubation Period
There is an incubation period of 3-14 days (usually about 4-7).

Signs and Symptoms

1. Rapid deterioration Deterioration occurs after 2–5 days of the typical symptoms of
dengue fever
2. Irritability Associated with rapid deterioration
3. Restlessness Associated with rapid deterioration
4. Low blood pressure Related to hemorrhage
5. Weak and rapid pulse Related to hemorrhage
6. Petechial rash Related to hemorrhage

Stages of Dengue Hemorrhagic Fever

* Grade I: fever + Herman's sign (flushes and redness of skin with lighter color at the
center of the rash)
* Grade II: Grade I symptoms + bleeding (epistaxis or nosebleeding, gingival bleeding,
hematemesis or upper gastrointestinal bleeding; e.g: vomiting of blood), and melena or
dark stool.
* Grade III: Grade II + Circulatory Collapse (hypotension, cold clammy skin and weak
pulse)
* Grade IV: Grade III + Shock.

Diagnostic Tests
1. Complete blood count to detect elevated white blood cell count, decreased platelet
count (thrombocytopenia), and increased hematocrit.
2. Blood test for antibodies.
3. Ask the client about a history of travel to tropical or subtropical areas.

Complications list for Dengue fever:

The list of complications that have been mentioned in various sources for Dengue fever
includes:

• Fatigue ,Tiredness ,Dengue hemorrhagic fever - this can cause several serious
complications(Bleeding ,Shock, Very low blood pressure ,Death)

Medical Management
Because dengue fever is caused by a virus, there is no specific medicine or antibiotic to
treat it. For typical dengue, the treatment is purely concerned with relief of the symptoms
(symptomatic). Rest and fluid intake for adequate hydration is important. Aspirin and
nonsteroidal anti-inflammatory drugs should only be taken under a doctor's supervision
because of the possibility of worsening hemorrhagic complications. Acetaminophen
(Tylenol) and codeine may be given for severe headache and for the joint and muscle
pain (myalgia).

Management
Do not give Aspirin because it contains at antiplatelet property which prmotes bleeding.
Treatment is solely supportive and includes:
* Fluids.
* Analgesics (not aspirin) for fever and muscles aches.
* Replacement of plasma or plasma expanders.

Nursing Management Dengue is a self-limited illness but recovery might take a

few weeks.

Independent:
 Close monitoring of vital signs in critical period (between days 2 to day 7
of fever) is critical.
 Increased oral fluid intake is recommended to prevent dehydration.
 Treatment is purely concerned with relief of the symptoms (symptomatic).

Dependent:
 Because dengue is caused by a virus, there is no specific medicine or
antibiotic to treat it.
 Aspirin and nonsteroidal anti-inflammatory drugs should be avoided as
these drugs may worsen the bleeding tendency associated with some of
these infections.
 Acetaminophen (Tylenol) and codeine may be given for severe headache
and for the joint and muscle pain (myalgia).
 (DHF) Oxygen and sedatives may be administered.

Collaborative:
 A platelet transfusion is indicated in rare cases if the platelet level drops
significantly (below 20,000) or if there are significant bleeding.
 The presence of melena or blood in the stool may indicate internal
gastrointestinal bleeding requiring platelet and/or red blood cell
transfusion.

Prevention of Dengue hemorrhagic fever:

Methods of prevention of Dengue hemorrhagic fever mentioned in various sources
includes those listed below. This prevention information is gathered from various
sources, and may be inaccurate or incomplete. None of these methods guarantee
prevention of Dengue hemorrhagic fever.

• See prevention of dengue

• Avoid mosquito bites
• Mosquito repellant
• Protective clothing
• Window screens
• Remove water-filled mosquito breeding areas
• Dengue vaccine - not yet available but being researched.
• See also prevention of mosquito bites
• See also prevention of mosquito-borne diseas

PATIENT’S PROFILE

Name: Miss X
Age: 22
Gender: Female
Address: 141 Sitio Salvacion Tunasan Muntinlupa City
Date of Birth: September 9, 1987
Place of Birth: Muntinlupa City
Nationality: Filipino
Religion: Roman Catholic
Civil Status: Single
Occupation: Toshiba Employee
Date of Admission:
Time of admission:
Physician:
Place of Admission: Biñan Doctors Hospital
Admitting Diagnosis: Dengue Fever Syndrome

A.1 CHIEF COMPLAIN

Fever
Patients Hx
• The patient complains of abdominal pain, headache, fever and general
flushing of skin with on and off vomiting.

a.2 PRESENT ILLNESS

• Four days prior to admission, the patient had an intermittent fever
associated with abdominal pain, headache, and general flushing of the
 skin with on and off vomiting. A few hours prior to admission still the above
sign and symptoms remain but already have (-) vomiting with
accompanying chills and was diagnosed with Dengue fever Syndrome.

a.3 PAST MEDICAL YEARS

• It was according to the patient that she wasn't been hospitalized yet not
until when she was diagnosed with Dengue Fever Syndrome. Before that
diagnosis, she was already experiencing fever and her mom gives her a
Paracetamol for remedy.

a.4 FAMILY HISTORY

• According to her grandmother the only disease that the family has
genetically is Diabetes Mellitus and no other diseases noted.

a.5 SOCIAL HISTORY

• Miss X is the daughter of Mr. and Mrs. SJ. CJS is currently working at
Toshiba as an employee at Sta. Rosa Citys.
• Her father works as a seaman while his mother is a housewife; her
grandmother is also living with them. Hence, her grandmother and her
mother were the ones responsible in all the household chores.

According to Miss X, she eats vegetables and fish instead she prefers
eating hotdogs. Furthermore she has no vices except for computer
games. After working hours, she goes directly at home to relax.

a.6 ENVIRONMENTAL HISTORY

• According to the patient the environment that the family has an open
drainage, wherein big rats and cockroaches can be seen. The house is
cleaned by her mother and grandmother. It was described by the patient that
there are parts of their house that is deprived from light.

C. HISTORY OF ILLNESS
• During the mid of, Miss X, started experiencing fever that persist only at night.
As a remedy her mom gave her Paracetamol to lower her body temperature.
Except from fever she’s also experiencing abdominal pain, headache and
general flushing of the skin with on and off vomiting.

As the above signs and symptoms persists, her parent decided to bring
her to the hospital.

Upon the physical assessment and after several diagnostic procedures

that the patient had undergone, she was diagnosed with Dengue Fever
Syndrome (DFS) and was admitted under the service of Dr. Olivares.

THEORETICAL FRAMEWORK

Miss X, , was diagnosed of having Dengue Fever Syndrome (DFS).At the

clinical check-up, the physician was able to identify some clinical signs of it and
was referred to Dr. Olivares. The case of Miss X can be correlated with the
theory of Florence Nightingale .

Application Theory:

The case of CJS can be correlated with the theory of Nightingale wherein,
the environment of the patient is a factor leading to recovery. Having a clean,
well ventilated and quite environment is important in. With a nurturing
environment, the body could repair itself.
 PHYSICAL ASSESSMENT
(Normal Findings Actual Findings Rationale)

Area Assessed Method Used Normal Findings Actual Findings Rationale

SKIN
Color and Inspection Light to deep brown General flushing Decrease WBC
pigmentation in the body
Lesions Inspection No lesions, scars or inflammation No lesions, but Normal
Texture Palpation Smooth presence of scars Normal
Moisture Palpation Moist Smooth Normal
Temperature Palpation The skin springs back to its previous Moist Normal
Mobility and turgor Palpation state after being pinched The skin springs Normal
back
to its previous state
NAILS after being pinched
Nail bed color Inspection Pink Pale Decrease RBC
Shape Inspection Convex Convex in the body
Lesions Inspection No inflammation of No inflammation of Normal
Thickness Palpation the skin around the nail the Normal
capillary refill Palpation Firm skin around the nail Normal
Firm Normal
Normal capillary (less than 3secs)
refill
HEAD
Size Inspection Proportion to the body Proportion to the Normal
Symmetry Inspection and the skull is body Normal
rounded and smooth and the skull is
Symmetrical rounded
and smooth
HAIR Symmetrical Normal
Color Inspection Black No nits/lice present Normal
Texture Inspection Curly hair, straight Normal
Other findings Inspection No nits/lice present

SCALP
Distribution of hair Inspection Evenly distributed No inflammation, Normal
Lesions Inspection No inflammation, lumps Normal
Other findings Inspection lumps or masses or masses Normal

FACE
Skin color Inspection Light to deep brown Pinkish Due to fever
Texture Inspection Smooth Symmetric facial Normal
Facial movement Inspection Symmetric facial Symmetric facial Normal
movement movement

EYES
External structure Inspection Evenly distributed
Eyebrows Inspection Evenly distributed, Pink conjunctiva Normal
Eyelashes Inspection Evenly distributed, curved outward Evenly distributed Normal
Eyelids Inspection Evenly distributed Normal
EARS Same as facial color Symmetric to head
Color Inspection Symmetrical at the No discharges and
Symmetry Inspection level of the eyes inflammation Normal
Shape and size Inspection corner Normal Normal
Symmetric to head Normal
No discharges and
inflammation
Same as facial color

NOSE Same with facial color Same with facial

Color Inspection Symmetric color
Shape Inspection No discharges Symmetric Normal
Discharges Inspection No discharges Normal
Normal

MOUTH Symmetric
Lips Inspection Pink Symmetric
Symmetry Inspection Moist Pink Normal
Moisture Inspection Dry Normal
D/t poor
TONGUE Positioned at the nutrition
Position Inspection center can move Central position
Color Inspection freely Dull red Normal
Texture Inspection Dull red Smooth Normal
Mobility Inspection Smooth Can move freely Normal
Lesions Inspection Can move freely No lesions or Normal
No lesions or inflammation Normal
inflammation
NECK Head centered
Position Inspection Symmetrical Head centered
Symmetry Inspection Smooth movements Symmetrical Normal
Range of movements Inspection without discomfort Smooth Normal
Palpation Symmetric and at movements Normal
midline position without discomfort Normal
Symmetric and at
midline position

UPPER AND LOWER

EXTREMITIES Equal size
Size Inspection Symmetrical
Symmetry Inspection Evenly distributed Equal size Normal
Distribution of hair Inspection Light to deep brown Symmetrical Normal
Skin color Inspection No lesions, Evenly distributed Normal
Lesions Inspection deformities or Light to deep brown Normal
inflammation No lesions, Due to
deformities or disease
Temperature Inspection Normal inflammation

Normal Normal
 GORDON’S 11 FUNCTIONAL HEALTH PATTERN

BEFORE DURING INTERPRETATION

FUNCTION HOSPITALIZATION HOSPITALIZATION
Nutrition • Eats 3x a day • Mostly eat bread • The Doctor ordered DAT
• She loves to eat diet to the patient except
bread & dark colored food
processed foods
such as hotdog,
tocino, longanisa,
and others.
• She doesn’t eat
vegetables and
fish
• Seldom drinks
water • This time she • To replace fluid loss
frequently drinks
water
Elimination She is able to • She can still • Her condition doesn’t
urinate & urinate & affected her
defecate normally defecate by elimination pattern
everyday by herself even
herself without an
• She doesn’t assistance
have any
problem on her
elimination
• Defecates
usually early in
the morning
before going to
school
Sleeping • Has a regular • Disturbed • Due to adherence to
sleeping pattern sleeping pattern time of medication &
• Normal sleep is vital signs monitoring
6-8 hrs. per day
but she naps for
1-2 hrs in the
afternoon
Cognitive- • Has a normal • She is responsive • Portraying
Perceptual cognitive & can cooperativeness
Pattern perception communicate well
• Can comprehend
well
• She responds
appropriately to
 verbal & physical
stimuli
Health Perception • She perceived • She thinks that • Due to her illness
Self-–Perception-
Health • Perceived herself
her health in the • This
she istimes
not he • Due to her ability to
Self concept
Management as a good friend, perceives herself establish good rapport
state of good healthy
Pattern brother
condition& as an to other people
DAughter. approachable
person
Role Relationship • He was able to • This time his role • Due to his condition,
Pattern do his as a patient is not she is not aware of
responsibilities as fully met performing her real role
a son & brother in this field.
Sexuality- • She thinks of • Same • Due to her age, it is still
Reproductive having a not her priority in life
Pattern boyfriend &
getting married.
Coping Stress & • She doesn’t fully • Same • At her age, she still has
Tolerance Pattern identifies her a playful mind & she
stressors. doesn’t mind the
stressors in life.
Activity-Exercise • Her daily routine • She interacts with • She only focuses on
Pattern on playing his grandmother simple things.
computer. Her & other people
daily activities around her
were limited in • Cooperates well
waking up in the to the doctor &
morning to attend nurses.
his class & after
that going to
computer shop.
Value-Belief • She is a Catholic • Due to their culture
Pattern preferences & parent’s
influence

Anatomy And Physilology

The Circulatory System

The tiniest of the blood vessels, and the place where the exchange of nutrients
and waste products takes place between the blood and the tissue fluids, is the
capillaries.
 The Lymphatic System
An often overlooked part of the circulatory system is the lymphatic system. As blood
passes through the capillaries, some of the fluid diffuses into the surrounding tissues. One
function of the lymphatic system is to collect and recycle this fluid (called lymph).
Lymph passes from capillaries to lymph vessels and flows through lymph nodes that are
located along the course of these vessels. Cells of the lymph nodes phagocytize, or ingest,
impurities such as bacteria, old red blood cells, and toxic and cellular waste. Finally,
lymph flows into the thoracic duct, a large vessel that runs parallel to the spinal column,
or into the right lymphatic duct, both of which transport the lymph back into veins of the
shoulder areas where is mixes with blood and is returned to the heart. All lymph vessels
contain one-way valves, like the veins, to prevent backflow.

The tissues of the lymphatic system include the spleen. The spleen serves as a reservoir
for blood, releasing additional blood into the circulatory system as needed. It is also
involved with destruction of old cells and other substances by phagocytosis. The
lymphatic system is also responsible for collecting nutrients that the digestive system has
extracted from our foods, and is a very important part of the immune system. We will
cover the lymphatic system in detail in the lesson on the immune system.

Babyrlene P. Añabieza Miss

Edith Vizcarra RN, MAN
BSN 4A
Clinical Instructor
“Journal of Ultrastructural studies on
dengue virus type 2 infection of
cultured human monocytes”

Background

Early interaction of dengue virus and

monocyte/macrophages could be an important feature for
virus dissemination after its initial entry via the mosquito
vector. Since ultrastructural analysis of this interaction has
not been reported, dengue type 2 (DEN2) virus-infected
human monocyte cultures were studied at 1, 2, 4 and 6
hours after infection.

Results

Typical dengue particles and fuzzy coated viral particles

were 35 to 42 nm and 74 to 85 nm respectively. Viruses
were engulfed by phagocytosis and macropicnocytosis
leading to huge vacuoles and phagosomes inside the
monocytes. Interaction of monocytes with DEN2 virus
induced apoptosis, characterized by nuclear condensation
and fragmentation, cellular shrinkage, blebbing and budding
phenomena and phagocytosis of apoptotic cells by
neighboring monocytes. This finding was confirmed by
TUNEL. Ultrastructural features associated to DEN2 virus
replication were not observed.

Conclusion

These data suggest that clearance of the virus by monocytes

and cellular death are the main features during the initial
interaction of DEN2 virus and monocytes and this could be
important in the rapid elimination of the virus after infection
by mosquito vector.

Reference: Halstead SB, O'Rourke EJ, Allinson AC: Dengue virus and
mononuclear phagocytes. II. Identity of blood and tissue leukocytes supporting in
vitro infection.
 Brand name/ Classification Action Indication Adverse Effect Contraindication Nursing
Generic name consideration
Acetaminophen Nonopoiod Produce Symptomatic Rash, nausea, Hypersensitivity. Patients with
(Paracetamol) analgesics and analgesia relief of pain and vomiting, blood Patients alcoholic liver
anti pyretics by blocking fever. Relief of dyscrasias , disease.
pain headache, anemia, analgesic Impaired liver
impulses by toothachge, back nephropathy , or kidney
inhibitinfg pain, nephrotoxicity , function
synthesis of dysmenorrheal, hypersensitivity
prostaglandi myalgias,neuralg reactions
n in the ias, etc.
CNS or of Analgesics and
other anti pyretic for
substances patients
that hypersensitive to
sensitize aspirin
pain
receptors to
stimulation.
 Brand name/ Classification Action Indication Adverse Effect Contraindication Nursing
Generic name consideration
Generic Name: Classificatio . Inhibits > Drugs that >Assess pt for
Ciprofloxacin n: bacterial > Infections of > Drugs that inhibit previous
Anti- DNA the resp. tract, inhibit peristalsis. sensitivity
Brand Name: infectives gyrase thus middle peristalsis. Infants and reaction
Pharex preventing ear,paranasal Infants and children, >Assess pt for
Ciprofloxacin replication sinuses, eyes, children, growing any s/s of
in kidneys, urinary growing adolescents. infection
susceptible tract adolescents. Pregnancy and before &
bacteria Pregnancy and lactation during
lactation treatment
>Assess for
adverse
reactions
>assess pt. &
family’s
knowledge of
drug therapy
 Brand name/ Classification Action Indication Adverse Effect Contraindication Nursing
Generic name consideration
Generic Name: Classificatio .
n
Brand Name:
ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATIO
DIAGNOSIS EXPLAINATION N
Subjective: Acute pain .This is due to With in 30 Independent: Goal Partially
“Masakit ang related to Entry of pathogens minutes and for met,
tiyan ko” as inflammatory in circulation the whole >monitor v/s > To determine After 30 hour
verbalized by the response as leading to release of period of duty alteration in present of nursing care
patient. evidenced by anti-inflammatory the patient will condition the patient
verbalization
Objective: of patient “
mediators and as a be free from >Instructed to >Helps relieving was able to
>C pain scale of masakit po vascular response it pain from 7/10 deep breathing pain reduced pain
7/10 tiyan ko” pain cause increase in to 1/10 excersise felt from 7/10
>grimace noted scale of 7/10, capillary >Encourage to >To divert attention to 5/10 as
>irritable grimace & permeability have Diversional from and reduce evidenced
>weakness noted irritability leading to activities like pain felt verbalization
Characteristic: hyperemia and watching t.v. of the patient
Stabbing, cellular exudation, >Place patient in >To provide
shooting pain swelling and pain a comfortable comfort
Onset: position
“pasumpong
>Encourage to >To have energy
sumpong po eh”
as verbalized by
have adequate
patient bed rest
Location: >Provided > Helps in relieving
No exact therapeutic touch pain
Location” sa
buong tiyan poh Dependent:
as verbalization
Duration: 2-3 >Administered
minutes Ranitidine as
Exacerbations: ordered
Gets worst when
pressure is
applied in the
stomach
Radiation:
Radiates in the
whole abdomen
Relief: “ kapag
iniipit ko tiyan ko
nwawala minsan
sakit”

>skinwarm to Elevated Entry of pathogens Within 30-1 Independent:

touch body in the systemic hour of nursing Goal met,
>flushed skin temperature circulation leading intervention & > Rendered >To promote After 45
>temp. 38 related to to regulation of for the whole sponge bath Surface cooling and minutes of
>c dry lips presence of toxins in the body period of duty allow heat to nursing care,
infection or and release of the patient release the patient
inflammatory pyrogens causig temperature will >Encourage to >To replace fluid temperature
response as stimulation of decrease with in increase oral fluid loss due to body decrease from
evidenced hypothalamus the normal intake heat 38C to 36.8 as
by temp- 38, leading to increase range from 38 to >Promote Surface >To release heat evidenced by
flushed and of thermoregulation 37 C cooling, loosen through evaporation normal temp
warm skin to and increase in clothing, and cool and conduction and absence
touch body tempertature environment of flushing and
>Encouraged to >To reduce cool skin
have adequate metabolic demand
bed rest and regain energy
Dependent:
>Administer >To decrease
Paracetamol as temperature and
ordered support circulating
volume and tissue
perfusion
 PATHOPHYSIOLOGY

Predisposing Factor: Non- predisposing

-Immuno Factor:
Examcompromised Result Normal Values - Age: Interpretation
- Environment - Female
Increase WBC indicates
WBC 12.8 5 – 10 x 10 ^/L Leukocytosis can be a sign of
infection.

Increase Segmenters indicates the

presence of an acute bacterial
Segmenters 0.90 0.60 -0.70
infection or some inflammation
going on inside the body

Decrease Lymphocytes indicates

Lymphocytes 0.08 0.20 – 0.40
can be sign of infection.

Hgb 116 140 -180 Normal

Hct 0.35 0.40 – 0.54 Normal

Platelets Count 110 150 – 450 x 10 ^/ L Due to presence of bleeding

↓
Bite of aedes aegypti mosquito carrying a virus
↓
Virus goes into the circulation
↓
Infects cells & generate cellular response
↓
Initiates destruction of the platelet
↓
↑ Potential for hemorrhage
 ↓
Stimulates intense inflammatory response
▼ ▼
Release of exogenous pyrogens body releases anti-
↓ inflammatory mediators
↑ WBC (Neutrophils & Macrophages) (Histatin, Kinins)
↓ ↓
Release of endogenous pyrogens Vascular response
↓ ↓
Reset of hypothalamic thermostat Redness & Heat
↓ ↓
Fever Headache, Vomiting
▼ ▼ Epistaxis, Abdominal pain
Muscle contract Blood vessels Circulatory Collapse Shock
To produce construct to ↓
Additional heat prevent loss of body heat DEATH
↓ ↓
SHIVERING CHILLS

Discharge Planning

A. Patient's Name:
> C.J.S a thirteen year-old male patient, who was diagnosed with Dengue
Hemorrhagic Fever.

B. Diet:
> Encourage nutritious foods like vegetables, meat and fruits.

C. Medications:
> Give acetaminophen in case the temperatures increases.
> Give oresol to replace fluid in the body.

D. Treatment:
> Increased oral fluid intake.

E. 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 at home to kill or reduce mosquito.
> E- Encourage the family of the patient to clean the surroundings to destroy the
breeding places of mosquito.