Textbook Discussion Dengue Hemorrhagic Fever Definition: Dengue hemorrhagic fever is a disease condition caused by one of the four

serotypes of the dengue virus (Flavivirus- genus Flaviridae). It is characterized by upper abdominal pain, intermittent fever with temperature of 37.8C and above, epistaxis, body malaise, muscle pain, skin petechiae, bleeding and in severe cases, may lead to hypovolemic shock. It starts abruptly with high continuous fever and headache with respiratory and intestinal symptoms such as sore throat, cough, nausea, vomiting and abdominal pain. Shock usually occurs after 2-6 days with sudden collapse if not given immediate care. There is bleeding with easy bruising, petechiae, vomiting blood (hematemesis), blood in the stool (melena), bleeding in the gums and epistaxis. Pneumonia and heart inflammation may also be present in severe cases. The mortality is appreciable ranging from 6% to 30%. Most deaths occur in children- with infants especially at risk for death. DHF is most prevalent in tropical countries. Grading of Dengue Hemorrhagic Fever Grade I- without spontaneous bleeding but positive for tourniquet test and thrombocytopenia Grade II- with bleeding (epistaxis, hematemesis, and skin petechiae), hepatomegaly and splenomegaly present Grade III- with bleeding as in grade II, rapid, weak pulse, with narrowing pulse pressure of 20mmHg or hypotension, hepatomegaly and splenomegaly present, cold clammy skin and restlessness Grade IV- profound shock wherein pulse and BP are not detectable, with clinical manifestations of grades II and III Clinical Manifestations: Found in the textbook Sudden onset of fever which lasts for 2-7 days Joint and muscle pain Body malaise Skin rashes (Hermans rash) Petechiae Epistaxis Abdominal pain Vomiting of coffee-colored matter Dark-colored stools Risk Factors Poor environmental sanitation Age (<15 y. o.) Predominantly affected are the preschool age and school age Peak age affected at 5-9years As manifested by the patient: (+) Aug. 15, 2010 (-) (+) August 31, 2010 (+) August 31, 2010 (+) August 31, 2010 (-) (+) August 31, 2010 (-) (-)

Compromised immune system Prevalent in tropical countries Epidemic usually occurs in the rainy seasons, June to November. Peak months are September and October. Previous existing anti-dengue antibody, either caused by previous infection or to maternal antibody passed to infants Host genetics :whites may be at greater risk and blacks at lower risk

MANAGEMENT Nursing Management 1. Monitor vital signs. 2. Perform tepid sponge bath for 30 min to relieve fever; assess temperature thereafter. 3. Advice patient to avoid eating dark-colored foods as it can interfere in assessing the stool and vomitus. 4. For Hemorrhage: Keep the patient at rest during bleeding episodes For nose bleeding, maintain an elevated position and promote vasoconstriction in nasal mucosa membrane through an ice bag over the forehead. For melena, put ice bag over the abdomen It transfusion is given, support the patient during the therapy. Observe for signs of deterioration: decreased PR, cold clammy perspiration, low BP, narrowing of pulse pressure. 5. For shock: Place patient in dorsal recumbent position to promote circulation Provision of warmth- through lightweight covers (overheating causes vasodilation which aggravates bleeding). 6. For diet: Low fat, low fiber, non-irritating foods No dark colored foods Medical/Surgical Management 1. 2. 3. 4. 5. Administer fluids and electrolytes to correct electrolyte imbalances and to prevent dehydration. Administer medications if indicated. Note: do not give aspirin as it is an anticoagulant which promotes bleeding Blood transfusion (FFP, Cryoprecipitate, Plasma Concentrate) Administer oxygen at 2 LPM.

Bronchopneumonia Bronchopneumonia is an illness of the lungs which is caused by different organism like bacteria, viruses, and fungi and characterized by acute inflammation of the walls of the bronchioles and alveoli. Streptococcus pneumonia (pneumococcus) and mycoplasma pneumuniae both are the common bacterium which causes bronchopneumonia in the adults and children.

Acute inflammation to the walls of the smaller bronchial tubes, with varying amounts of pulmonary consolidation due to spread of the inflammation into peribronchial alveoli and the alveolar ducts; may become confluent or may become hemorrhagic. Risk Factors: Advanced age History of smoking Upper respiratory tract infection Tracheal intubation Prolonged immobility Immunosuppressive therapy Nonfunctional immune system Malnutrition Dehydration Chronic disease states such as diabetes, heart disease, chronic lung cancer, renal disease, and cancer. As manifested by the patient: (-) (+) August 15, 2010 (-) (+) August 31, 2010 (-) (-) (-) (+) August 31, 2010 (-) (-) (-)

Found in the textbook Productive cough with greenish or yellowish mucus Fever Chest pain Dyspnea Shortness of breath Headache Loss of appetite Fatigue Chills Night sweats Hemoptysis MANAGEMENT Nursing management

1. Perform a comprehensive nursing history which includes presence and character of any chest pain and presence and character of cough and sputum production. 2. Perform respiratory assessment every 4 hours. 3. Teach client to avoid conditions that increase oxygen demand. 4. Monitor cognitive functioning. 5. Encourage movement and exercise between rest periods to prevent worsening of the pneumonia. 6. Administer antibiotics as ordered. 7. Encourage to increase fluid intake (2-3 liters/day) and monitor swallowing disability. 8. Monitor fluid balance (intake and output closely). 9. Administer oxygen therapy as ordered.

10. Postural drainage 11. Perform chest physiotherapy 12. Perform tracheal suction if patient is too weak to cough.

Medical management 1. Specific antibiotic therapy, respiratory support as needed, nutritional support and fluid and electrolyte management. 2. Initial drug therapy of broad-spectrum antibiotics.

References: Porth, C.M. Pathophysiology, Cooncepts of Altered Health States. 7th ed., 2005 Cuevas, F.P. Public Health nursing in the Philippines. 10th ed., 2007 Black, J.M. Medical-Surgical Nursing, Clinical Managements for positive outcomes. 7th ed. 2005 Smeltzer, S. (et. Al). Textbook of Medical-Surgical nursing. 12th ed. 2010