INTRODUCTION

Infection by any one of the four serotypes of dengue virus (DENV) remains asymptomatic in
the vast majority. Clinical spectrum among symptomatic infection ranges from undifferentiated
fever (viral syndrome), dengue fever (DF), and dengue haemorrhagic fever (DHF) to the
expanded dengue syndrome with isolated organopathy (unusual manifestations). DF can be
without haemorrhage or have unusual haemorrhage, while DHF can be without shock or with
shock, that is, dengue shock syndrome.

The WHO criteria for the clinical diagnosis of DHF requires the presence of acute and
continuous fever of 2 to 7 days, haemorrhagic manifestations associated with thrombocytopenia
(100,000 cells/c.mm or less) and haemoconcentration (haematocrit >20% from baseline of
patient or population of same age). Haemorrhagic manifestations could be mucosal and or skin
or even a positive tourniquet test which is the commonest. Hepatomegaly occurs at some stage
of DHF and often precedes plasma leakage and hence a valuable early predictor of plasma
leakage.

DHF is most commonly seen in children with secondary dengue infection but has been
documented in primary infection with DENV-1 and DENV-3, as well as in infants. These infants
had acquired maternal dengue antibody and subsequently experienced a dengue infection.
Greater baseline vascular permeability among children could also be a contributor for more
severe disease among children than among adults. Epidemiological and serological studies
done both in Thailand and Cuba support the importance of secondary dengue infections as a
risk factor for DHF. Since the first observations by Halstead et al. in 1970, DHF has been
present in situations where more than one serotype circulates. The disease burden and a
resurgence of recurrent epidemics of DHF are attributable to social dynamics and a variety of
epidemiological factors such as a high vector density, a high virus circulation, and a population
at risk of secondary infection by virtue of previous exposure. Besides secondary infection,
chronic diseases such as bronchial asthma and diabetes have been suggested as risk factors
for DHF. Also, whites have higher risk of developing DHF than blacks. DENV-2 virus is known to
replicate to higher concentration in the peripheral blood cells of whites compared with those of
blacks.

1
 Some patients with dengue fever go on to develop dengue hemorrhagic fever (DHF), a
severe and sometimes fatal form of the disease. Around the time the fever begins to subside
(usually 3–7 days after symptom onset), the patient may develop warning signs of severe
disease.

During week 36, 2019, a total of 13,059 dengue cases were reported nationwide. As of 31
August 2019, the cumulative number of cases was 292,076 with 1,184 deaths This is higher
compared to 135,490 cases with 690 deaths reported during the same period in 2018. The
Philippines has a high dengue incidence and has already initiated a school-based dengue
vaccination program in Manila. These estimates of the disease burden of dengue should help
inform and refine policy decisions and increase understanding of dengue among the public.

Thus far, 2019 has been a year marked by several dengue epidemics, from Latin
America to Southeast Asia. Data from the Pan American Health Organization (PAHO)
indicate about 236,372 total possible cases, with nearly 80,000 laboratory -confirmed
cases and 68 deaths this year in the Americas alone. The current total 2019 cases for
the region is estimated to already be 42% of the total 2018 cases (561,233 cases),
indicating that 2019 totals may potentially surpass those of 2018. This week, Outbreak
Observatory explores dengue epidemiology and several challenging factors that are
limiting our ability to control this disease.

Warning signs include severe abdominal pain, persistent vomiting, marked change in
temperature (from fever to hypothermia), hemorrhagic manifestations, or change in mental
status (irritability, confusion, or obtundation). The patient also may have early signs of shock,
including restlessness, cold clammy skin, rapid weak pulse, and narrowing of the pulse pressure
(systolic blood pressure − diastolic blood pressure). Patients with dengue fever should be told to
return to the hospital if they develop any of these signs.

The most common hemorrhagic manifestations are mild and include a positive tourniquet
test, skin hemorrhages (petechiae, hematomas), epistaxis (nose bleed), gingival bleeding (gum
bleed), and microscopic hematuria. More serious types of hemorrhage include vaginal bleeding,
hematemesis, melena, and intracranial bleeding. Many health organizations suggest the
following to protect yourself from dengue:Wear long-sleeve shirts and long pants. Treat clothes
with repellents like permethrin. Use EPA-registered mosquito repellent like DEET, Consider

2
using mosquito netting if you will be in an areas with many mosquitoes. Make sure windows and
doors screens are closed to avoid allowing mosquitoes into inclosed spaces. Avoid areas with
standing water. Especially at times of high mosquito activity like dawn and dusk.Passport Health
locations carry kits specifically designed to help prevent mosquito bites and mosquito-borne
disease. Be sure to take one with you on your next trip.

Even for outpatients, stress the need to maintain adequate hydration. Monitoring for warning

signs of severe dengue and initiating early appropriate treatment are key to preventing

complications such as prolonged shock and metabolic acidosis. Successful management of

DHF and DSS includes judicious and timely IV fluid replacement therapy with isotonic solutions

and frequent reassessment of the patient’s hemodynamic status and vital signs during the

critical phase. Health care providers should learn to recognize this disease at an early stage. To

manage pain and fever, patients should be given acetaminophen. Aspirin and nonsteroidal, anti-

inflammatory medications may aggravate the bleeding tendency associated with some dengue

infections and, in children, can be associated with the development of Reyes syndrome.

Complications from severe or acute dengue hemorrhagic fever may include seizures, brain

damage, blood clots, damage to the liver and lungs, heart damage, shock and death. Prompt

treatment can help prevent complications.

3
PATHOPHYSIOLOGY

4
 NURSING CAREPLANS

Assessment Diagnosis Goal Intervention Evaluation

SUBJECTIVE: Hyperthermia At the end of my five INDEPENDENT: 1. Goal met as evidenced by

related to illness hour shift, the patient maintained core temperature
“I do have high will be able to:  Assess underlying within normal range.
fever” as DEFINITION: cause
verbalized by Body 1. maintain core  Monitor vital signs 2. Goal met as evidenced
the patient. temperature temperature  Monitor respirations byidentified underlying cause or
within normal
elevated above
range
 Monitor and record all contributing factors and
OBJECTIVE: normal range. sources of fluid loss importance of treatment, as well
such as urine vomiting as sign and symptoms requiring
2. Identify
 Increase REFERENCE: underlying cause and diarrhea; wounds, further evaluative or intervention.
body Nurses Pocket or contributing fistulas; and insensible
temperature Guide 12th factors and losses 3. Goal met as evidenced by
above normal edition by importance of  Maintain bed rest demonstrated behaviors to
range. Marilynn E. treatment, as  Administer monitor and promote
 Flushed skin; Doenges, well as sign and
replacement fluids and normothermia.
warm to Mary Frances symptoms
requiring further electrolytes
touch Moorhouse,  Discuss importance of 4. Goal met as evidenced by free of
evaluative or
 Tachycardia Alice C. Murr
intervention. adequate fluid intake. seizure activity.
 Seizures  Administer medications
3. Demonstrate as ordered
T- 40.2 °C behaviors to
P- 113 bpm monitor and
R- 40 cpm promote
BP- 90/50 normothermia
mmHg
4. Be free from
seizure activities

5
Assessment Diagnosis Goal Intervention Evaluation

SUBJECTIVE: Deficient fluid At the end of my five INDEPENDENT: 1. Goal met, as evidenced by client’s
volume related to hour shift, the patient  Assess vital response to interventions, teaching,
“Im feeling so failure of will be able to: signs, noting low and actions, performed
weak these regulatory BP-severe
days” as mechanism 1. Maintain fluid hypotension, 2. Attainment or progress towards
verbalized by volume at a rapid heartbeat, desired outcome
the patient. DEFINITION: functional level as and thread
Decreased evidenced peripheral pulses 3. Modification to plan of care
OBJECTIVE: intravascular, individually  Establish 24hour
interstitial, and or adequate urinary fluid replacement
 Poor skin intracellular fluid. output with normal
needs and routs
turgor This refers to specific gravity,
to be used
stable vital signs,
 Decrease dehydration,
moist mucous  Change position
urine output water loss alone frequently
membranes, good
 Decrease without change
skin turgor and
blood in sodium. prompt capillary
pressure refill, resolution of  Provide frequent
 Elevated REFERENCE: edema oral and eye care
hematocrit Nurses Pocket
Guide 12th 2. Verbalize  Encourage
edition by understanding of increase OFI
VS: Marilynn E. causative factors  Recommend
T- 39 °C Doenges, and purpose of restriction of
P- 100 bpm Mary Frances individual caffeine alcohol
R- 30 cpm Moorhouse, therapeutic as indicated
BP- 90/50 Alice C. Murr interventions and
mmHg medications
DEPENDENT
 Administer
3. Demonstrate
behaviors to medications as
monitor and ordered
correct deficit as
indicated

6
Assessment Diagnosis Objectives Intervention EVALUATION

SUBJECTIVE: Ineffective At the end of my five 1. Goal met as evidenced by:

thermoregulation hour shift, the patient  Identify individual Verbalized understanding of
“how come my related to illness will be able to: factors or individual factors and appropriate
fever is on underlying interventions
and off?” as DEFINITION: 1. Verbalize condition
verbalized by Temperature understanding of  Initiate emergent 2. Goal met as evidenced by:
the patient. fluctuation individual factors or immediate Demonstrated techniques and
between and appropriate interventions behavior to correct underlying
OBJECTIVE: hypothermia and interventions  Prepare client condition or situation
hyperthermia and assist with
 Fluctuate in 2. Demonstrate procedures 3. Goal met as evidenced by:
body REFERENCE: techniques and Maintained body temperature within
temperature Nurses Pocket behavior to correct normal range.
above and Guide 12th underlying DEPENDENT:
below edition by condition or  Administer fluids,
normal Marilynn E. situation electrolytes and
range Doenges, medications, as
 Tachycardia Mary Frances 3. Maintain body appropriate
 Mild Moorhouse, temperature within
shivering Alice C. Murr normal range
 Slow
capillary refill

VS:
T- 39.2 °C
P- 97 bpm
R- 23 cpm
BP- 90/60
mmHg

7
REFERENCES

Dengue and dengue Hemorrhagic fever. (2009). Retrieved November 1, 2019, from
https://www.cdc.gov/dengue/resources/denguedhf-information-for-health-care-
practitioners_2009.pdf.

Hosangadi, D. (2019, March 21). The Global Rise of Dengue Infections. Retrieved from
https://www.outbreakobservatory.org/outbreakthursday-1/3/21/2019/the-global-rise-of-dengue-
infections

Undurraga, E. A., Edillo, F. E., Erasmo, J. N. V., Alera, M. T. P., Yoon, I.-K., Largo, F. M., &
Shepard, D. S. (2017, April). Disease Burden of Dengue in the Philippines: Adjusting for
Underreporting by Comparing Active and Passive Dengue Surveillance in Punta Princesa, Cebu
City. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5392638/.

Dengue Fever Prevention. (n.d.). Retrieved from https://www.passporthealthusa.com/travel-

medicine/dengue-fever-prevention/.
END STAGE RENAL DISEASE CASE STUDY

Candace F. Balbin, RN
Makati Medical Center
NRPP-BATCH 58
November 11,2019