Saint Michael’s College of LagunaSchool 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, ManClinical 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 agentIt is caused by four antigenically related but distinct serotypes of the dengue virus DEN-1, DEN-2, DEN-3 and DEN-4.

Mode of transmissionA 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 PeriodThere 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 RationaleSKINColor and pigmentationLesionsTextureMoistureTemperatureMobility and turgor

NAILSNail bed colorShapeLesionsThicknesscapillary refill

Inspection

InspectionPalpationPalpationPalpationPalpation

InspectionInspectionInspectionPalpationPalpation

Light to deep brown

No lesions, scars or inflammationSmoothMoistThe skin springs back to its previous state after being pinched

PinkConvexNo inflammation ofthe skin around the nailFirm

General flushing

No lesions, but presence of scars SmoothMoistThe skin springs backto its previous stateafter being pinchedPaleConvexNo inflammation of theskin around the nailFirmNormal capillary refill

Decrease WBCin the bodyNormalNormalNormalNormalNormal

Decrease RBCin the bodyNormalNormalNormalNormal (less than 3secs)

HEADSizeSymmetry

InspectionInspection

Proportion to the bodyand the skull isrounded and smooth

Proportion to the bodyand the skull is

NormalNormal

HAIRColorTextureOther findings

SCALPDistribution of hairLesionsOther findings

FACESkin colorTextureFacial movement

EYESExternal structureEyebrowsEyelashesEyelids

EARSColor

InspectionInspectionInspection

InspectionInspectionInspection

InspectionInspectionInspection

InspectionInspectionInspectionInspection

Inspection

Symmetrical

BlackCurly hair, straightNo nits/lice present

Evenly distributedNo inflammation,lumps or masses

Light to deep brownSmoothSymmetric facialmovement

Evenly distributedEvenly distributed,Evenly distributed, curved outward

Same as facial colorSymmetrical at the

roundedand smoothSymmetricalNo nits/lice present

No inflammation, lumpsor masses

PinkishSymmetric facialSymmetric facialmovement

Pink conjunctivaEvenly distributedEvenly distributed

Symmetric to headNo discharges and

NormalNormalNormal

NormalNormalNormal

Due to feverNormalNormal

NormalNormalNormal

SymmetryShape and size

NOSEColorShapeDischarges

MOUTH LipsSymmetryMoisture

TONGUEPositionColorTextureMobilityLesions

NECKPositionSymmetry

InspectionInspection

InspectionInspectionInspection

InspectionInspectionInspection

InspectionInspectionInspectionInspectionInspection

InspectionInspection

level of the eyescornerSymmetric to headNo discharges andinflammationSame as facial color

Same with facial colorSymmetricNo discharges

SymmetricPinkMoist

Positioned at thecenter can movefreelyDull redSmoothCan move freelyNo lesions orinflammation

Head centeredSymmetricalSmooth movements

inflammationNormal

Same with facial colorSymmetricNo discharges

SymmetricPinkDry

Central positionDull redSmoothCan move freelyNo lesions orinflammation

Head centeredSymmetrical

NormalNormalNormal

NormalNormalNormal

NormalNormalD/t poornutrition

NormalNormalNormalNormalNormal

Normal

Range of movements

UPPER AND LOWEREXTREMITIESSizeSymmetryDistribution of hairSkin colorLesions

Temperature

InspectionPalpation

InspectionInspectionInspectionInspectionInspection

Inspection

without discomfortSymmetric and atmidline position

Equal sizeSymmetricalEvenly distributedLight to deep brownNo lesions,deformities orinflammation

Normal

Smooth movementswithout discomfortSymmetric and atmidline position

Equal sizeSymmetricalEvenly distributedLight to deep brownNo lesions,deformities orinflammation

Normal

NormalNormalNormal

NormalNormalNormalNormalDue todisease

Normal

GORDON’S 11 FUNCTIONAL HEALTH PATTERN

FUNCTION BEFORE

HOSPITALIZATIONDURING

HOSPITALIZATIONINTERPRETATION

Nutrition Eats 3x a day She loves to eat

bread & processed foods such as hotdog, tocino, longanisa, and others.

She doesn’t eat vegetables and fish

Seldom drinks water

Mostly eat bread

This time she frequently drinks

water

The Doctor ordered DAT diet to the patient except dark colored food

To replace fluid loss

Elimination She is able to urinate & defecate normally everyday by herself

She doesn’t have any problem on her elimination

Defecates usually early in the morning before going to school

She can still urinate & defecate by herself even without an assistance

Her condition doesn’t affected her elimination pattern

Sleeping Has a regular sleeping pattern

Normal sleep is 6-8 hrs. per day but she naps for 1-2 hrs in the afternoon

Disturbed sleeping pattern

Due to adherence to time of medication & vital signs monitoring

Cognitive-Perceptual

Pattern

Has a normal cognitive perception

Can comprehend well

She responds appropriately to

She is responsive & can communicate well

Portraying cooperativeness

verbal & physical stimuli

Self- Perception-Self concept

Perceived herself as a good friend, brother & DAughter.

This times he perceives herself as an approachable person

Due to her ability to establish good rapport to other people

Role Relationship Pattern

He was able to do his responsibilities as a son & brother

This time his role as a patient is not fully met

Due to his condition, she is not aware of performing her real role in this field.

Sexuality-Reproductive

Pattern

She thinks of having a boyfriend & getting married.

Same Due to her age, it is still not her priority in life

Coping Stress & Tolerance Pattern

She doesn’t fully identifies her stressors.

Same At her age, she still has a playful mind & she doesn’t mind the stressors in life.

Activity-Exercise Pattern

Her daily routine on playing computer. Her daily activities were limited in waking up in the morning to attend his class & after that going to computer shop.

She interacts with his grandmother & other people around her

Cooperates well to the doctor & nurses.

She only focuses on simple things.

Value-Belief Pattern

She is a Catholic Due to their culture preferences & parent’s influence

Health Perception – Health

Management Pattern

She perceived her health in the state of good condition

She thinks that she is not healthy

Due to her illness

Anatomy And Physilology

The Circulatory SystemThe 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, MANBSN 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/ Generic name

Classification Action Indication Adverse Effect Contraindication Nursing consideration

Acetaminophen(Paracetamol)

Nonopoiod analgesics and anti pyretics

Produce analgesia by blocking pain impulses by inhibitinfg synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation.

Symptomatic relief of pain and fever. Relief of headache, toothachge, back pain, dysmenorrheal,myalgias,neuralgias, etc. Analgesics and anti pyretic for patients hypersensitive to aspirin

Rash, nausea, vomiting, blood dyscrasias , anemia, analgesic nephropathy , nephrotoxicity , hypersensitivity reactions

Hypersensitivity. Patients

Patients with alcoholic liver disease. Impaired liver or kidney function

Brand name/ Generic name

Classification Action Indication Adverse Effect Contraindication Nursing consideration

Generic Name:Ciprofloxacin

Brand Name: Pharex Ciprofloxacin

Classification: Anti-infectives

. Inhibits bacterial DNA gyrase thus preventing replication in susceptible bacteria

> Infections of the resp. tract, middle ear,paranasal sinuses, eyes, kidneys, urinary tract

> Drugs that inhibit peristalsis. Infants and children, growing adolescents. Pregnancy and lactation

> Drugs that inhibit peristalsis. Infants and children, growing adolescents. Pregnancy and lactation

>Assess pt for previous sensitivity reaction>Assess pt for any s/s of infection before & during treatment>Assess for adverse reactions >assess pt. & family’s knowledge of drug therapy

Brand name/ Generic name

Classification Action Indication Adverse Effect Contraindication Nursing consideration

Generic Name:

Brand Name:

Classification .

ASSESSMENT NURSINGDIAGNOSIS

SCIENTIFICEXPLAINATION

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:“Masakit ang tiyan ko” as verbalized by the patient.

Objective:>C pain scale of 7/10>grimace noted>irritable>weakness notedCharacteristic: Stabbing, shooting painOnset: “pasumpong sumpong po eh” as verbalized by patientLocation: No exact Location” sa buong tiyan poh as verbalizationDuration: 2-3 minutesExacerbations: Gets worst when pressure is applied in the

Acute pain related to inflammatory response as evidenced by verbalization of patient “ masakit po tiyan ko” pain scale of 7/10, grimace & irritability

.This is due to Entry of pathogens in circulation leading to release of anti-inflammatory mediators and as a vascular response it cause increase in capillary permeability leading to hyperemia and cellular exudation, swelling and pain

With in 30 minutes and for the whole period of duty the patient will be free from pain from 7/10 to 1/10

Independent:

>monitor v/s

>Instructed to deep breathing excersise>Encourage to have Diversional activities like watching t.v.>Place patient in a comfortable position>Encourage to have adequate bed rest>Provided therapeutic touch

Dependent:

>Administered Ranitidine as ordered

> To determine alteration in present condition>Helps relieving pain

>To divert attention from and reduce pain felt

>To provide comfort

>To have energy

> Helps in relieving pain

Goal Partially met,After 30 hour of nursing care the patient was able to reduced pain felt from 7/10 to 5/10 as evidenced verbalization of the patient

stomachRadiation: Radiates in the whole abdomenRelief: “ kapag iniipit ko tiyan ko nwawala minsan sakit”

>skinwarm to touch >flushed skin>temp. 38>c dry lips

Elevated body temperature related to presence of infection or inflammatory response as evidenced by temp- 38, flushed and warm skin to touch

Entry of pathogens in the systemic circulation leading to regulation of toxins in the body and release of pyrogens causig stimulation of hypothalamus leading to increase of thermoregulation and increase in body tempertature

Within 30-1 hour of nursing intervention & for the whole period of duty the patient temperature will decrease with in the normal range from 38 to 37 C

Independent:

> Rendered sponge bath

>Encourage to increase oral fluid intake>Promote Surface cooling, loosen clothing, and cool environment>Encouraged to have adequate bed restDependent:>Administer Paracetamol as ordered

>To promote Surface cooling and allow heat to release >To replace fluid loss due to body heat>To release heat through evaporation and conduction

>To reduce metabolic demand and regain energy

>To decrease temperature and support circulating volume and tissue perfusion

Goal met,After 45 minutes of nursing care, the patient temperature decrease from 38C to 36.8 as evidenced by normal temp and absence of flushing and cool skin

Exam Result Normal Values Interpretation

WBC 12.8 5 – 10 x 10 ^/LIncrease 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 0.08 0.20 – 0.40Decrease Lymphocytes indicates

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

PATHOPHYSIOLOGY

↓

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

Non- predisposing Factor:- Age:- Female

Predisposing Factor:-Immuno compromised - Environment

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.