I. INTRODUCTION

Dengue fever and dengue hemorrhagic fever are acute febrile diseases. Dengue is classified as mild, moderate and severe depending on symptoms manifested. It also has grading and staging from grade 1-4 based on severity and condition.

Dengue hemorrhagic fever (DHF), a potentially lethal complication, was first recognized in the 1950’s during the dengue epidemics in the Philippines and Thailand. Dengue Fever is caused by one of the four distinct virus serotypes Dengue type 1,2,3 and 4 of the Genus Flavivirus and Chikungunya Virus. Infection with one of this 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 serotypes are transmitted by Aedes Aegypti through bite. It becomes infected with the Dengue Virus when it bites a person who has Dengue and after incubation period of 6-10 days transmits the virus to healthy person. Dengue may also be transmitted via infected blood products, it cannot be transmitted or directly spread from person to person.

Clinical manifestation of Dengue Fever in severe type are frank type flushing, sudden high fever, severe hemorrhage, followed by sudden drop of temperature, shock and terminating in recovery or death. For moderate type high fever and spontaneous bleeding are present. For mild slight fever, with or without petechial hemorrhage are evident.

The mainstay of treatment is timely supportive therapy to tackle circulatory shock due to hemoconcentration and bleeding. Close monitoring of vital signs in the critical period. Oral rehydration therapy is recommended to prevent dehydration in moderate to severe cases. Supplementation with intravenous fluids may be necessary to prevent dehydration and significant concentration of the blood if the patient is unable to maintain oral intake. A platelet transfusion may be indicated if the platelet level drops significantly or if there is significant bleeding. The presence of melena may indicate internal gastrointestinal bleeding requiring platelet and/or red blood cell transfusion. Aspirin and non-steroidal anti-inflammatory drugs should be avoided as these may worsen the bleeding tendency associated with some of these infections. Patients may receive paracetamol, acetaminophen and preparation to deal with these symptoms if dengue is suspected.

The WHO says 2.5 billion people, are now at risk from dengue and estimates that there may be 50 million cases of dengue infection worldwide every year. All persons are susceptible and both sexes are equally affected. Dengue Fever is sporadic throughout the year. Epidemic usually occurs during rainy seasons (June-November) peak months are September-October.

II. OBJECTIVES

General

This case presentation aims to identify and determine the general health problems and needs of the patient with an admitting diagnosis of Dengue Hemorrhagic Fever Type 1. This presentation also intends to help patient promote health and medical understanding of such condition through the application of the nursing skills and for the students to gain knowledge, skills and attitude.

Specific

To raise the level of awareness of patient on health problems that she may encounter. To facilitate patient in taking necessary actions to solve and prevent the identified

problems on her own. To help patient in motivating her to continue the health care provided by the health

workers. To render nursing care and information to patient through the application of the nursing

skills.

III. NURSING HISTORY

GENERAL DATA

This is a case of CB, 5years old, male, from Pasig City. The patient is admitted for the first time at Rizal Medical Center last September 04, 2010 with a chief complaint of fever.

PRESENT HEALTH HISTORY

Three days prior to admission the patient experience intermittent fever of 38-39°C. They consult to a private physician and prescribed meds of co-amoxclav. Few hours prior to admission the patient is still with fever, with abdominal pain and CBC done platelet is 158.

PAST HEALTH HISTORY

The patient is never hospitalized before. He has no allergies on any substance or food.

FAMILY HEALTH HISTORY

No hereditary disease can be attributed from her father side, but her mother had a family health history of hypertension. Other than the latter, no other hereditary disease from both of his parents are within the patient’s mother knowledge.

ENVIRONMENTAL HISTORY

The patient lives near the riverside. They have some stocks of container with water that doesn’t have cover.

NUTRITIONAL HISTORY

The patient eats all kinds of food. He drinks 4-6 glasses a day.

ELIMINATION PATTERN

Elimination pattern for bowel is once a day. He doesn’t have any difficulty in urinating.

PSYCHOSOCIAL DEVELOPMENT

The patient is on his preschooler stage. He learns how to things and that doing a thing is desirable. He learns sexual identity through awareness of genital area.

IV. PHYSICAL ASSESSMENT

FINDINGSSeptember 06, 2010

FINDINGSSeptember 07, 2010

REMARKS

BLOOD PRESSURE 100/70 mm Hg 100/70 mm Hg NormalTEMPERATURE 38.9 °C 37.8 °C With feverPULSE RATE 98 bpm 96 bpm Normal RESPIRATORY RATE 19 bpm 20 bpm NormalGENERAL APPEARANCE Conscious and coherent Conscious and coherent Normal

HEAD TO TOE ASSESSMENT

AREA ASSESSED NORMAL FINDINGS ACTUAL FINDINGSSeptember 06, 2010

ACTUAL FINDINGSSeptember 07, 2010

REMARKS

HEAD

HAIR

SCALP

FACE

EYES

SCLERA

Round and symmetrical.

Smooth,without masses or depressions,non tender.

Can be black, brown or burgundy(no evidences of Alopecia), noparasites, and the amount isvariable

Moist, no scars, free from lice and dandruff

Symmetrical, no edema, no involuntary movements

Symmetrical or evenly placed andinline with each other.

Nonprotruding and equal palpebralfissure

white, moist and

Round and symmetricalSmooth, without mass and not tender

Black, smooth and no presence of parasites

Moist, no scars, no lice and dandruffs

Symmetrical, no edema, no involuntary movements

Symmetrical and non protruding

Symmetrical and non protruding

white, moist and

Round and symmetricalSmooth, without mass and not tender

Black, smooth and no presence of parasites

Moist, no scars, no lice and dandruffs

Symmetrical, no edema, no involuntary movements

Symmetrical and non protruding

Symmetrical and non protruding

white, moist and without

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL

CONJUNCTIVA

NOSE

MOUTH

EARS

NECK

LYMPH NODES

THORAX CHEST ANTERIOR

withoutlesions

shiny,smooth, and pink or red, absenceof swelling, no lesions and moist

Symmetrically, without swelling,bleeding, lesions, or masses. Nodischarge or flaring and uniformcolor,

pink, soft moist, smooth texture with no evidence of lesions or inflammation. Not crack and symmetrical.

Cerumen should bemoist and not obscure thelympanic membrane, no foreign bodies, redness,drainage, deformities, nodules orlesions

muscles of the neck aresymmetrical with the head at acentral position

Lymph nodes should not be visible or inflamed and not palpable

Quiet, rhythmic respiration.

withoutlesions

shiny, not swelling, pale in color

Symmetrical, no masses, no flaring, bleeding

pale in color, no lesions or inflammations

No deformities

Symmetrical

(+) palpable posterior cervical lymph nodes

Symmetrical chest expansion, clear breath

lesions

shiny, not swelling, slightly pale in color than before

Symmetrical, no masses, no flaring

Slightly pale in color than before, no lesions or inflammations

No deformities

Symmetrical

(+) palpable posterior cervical lymph nodes

Symmetrical chest expansion, clear breath sounds

Decrease RBC count

Decreased platelet count

Due to decreased RBC count

Normal

Normal

Presence of infection

Normal

ABDOMEN

UPPER AND LOWER EXTREMITIES

Normal breathing rate

no pain,tenderness, rigidity and muscleguarding

Extremities are equal in size

No involuntary movements

No lesions and edema

Temperature is warm and even

Can perform ROM

sounds

No pain, no tenderness

Warm to touch, with IV catheter hooked at right arm.

No pain, no tenderness

Warm to touch, with IV catheter hooked at right arm.

Normal

With fever due to infection

V. ANATOMY AND PHYSIOLOGY

VI. PATHOPHYSIOLOGY

MODIFIABLEEnvironment – near river side

NON-MODIFIABLEBoth sexes- male & female

Bite of Aedes Aegypti mosquito carrying virus

Stimulates inflammatory response

Viruses go into the circulation

Initiates destruction of platelets

↑ potential for hemorrhage

Fever of 38.9°C Loss of appetite Restlessness Platelet Count - 24Irritability

VII. LABORATORY FINDINGS

Normal Value September 06, 2010 September 07, 2010Hemoglobin 135.00-180.00 128 123Hematocrit 0.400-0.540 0.363 0.348Platelet Count 150-450 58 102

Laboratory Interpretation:

Decrease hemoglobin and hematocrit can rule out anemia due to blood loss and destruction of blood cells internally.

Decreased platelet count can rule out Rule out premature destruction states such as immune-mediated thrombocytopenia, acute blood loss.

VIII. NURSING CARE PLAN

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATIONSubjective Cues:“ Nilalagnat ang anak ko mainit po siya”, as the patient’s mother verbalized.

Objective Cues: Weakness Flush skin Warm to touch Pale Febrile – 38.9°C Loss of appetite

NURSING DIAGNOSIS

Hyperthermia related to infection

Short term goalAfter an hour of nursing intervention, the client’s temperature will subside from 38.9°C- 38.0°C.

Provide surface cooling such as TSB and removing of extra clothing.

Encouraged increase fluid intake.

Provide bed rest.

Administer Paracetamol 5ml p.o as ordered by the physician.

To promote core cooling by helping reduce body temperature.

To prevent dehydration because increase in body temperature causes fluid loss such as sweating.

To detect further existing discomfort and promote rest.

Paracetamol are classified as analgesics and antipyretic which acts on the Hypothalamus to regulate normal body temperature.

Patient condition improved

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATIONSubjective Cues:“Dumudugo ang ilong ng anak ko”, as the patient’s mother verbalized.

Objective Cues: Weakness Irritability Restlessness Pale Febrile- 38.9°C Platelet count – 58

NURSING DIAGNOSIS

Bleeding related to altered clotting factor

After an hour of nursing intervention, the client will be able to demonstrate behaviors that reduce the risk for bleeding.

Assess for signs of GI bleeding. Observe color and consistency of stools or vomitus.

Focus for presence of bleeding from one or more sites.

Inhibit of taking aspirin containing products

Monitor Hb and Hct and clotting factors

Increase fluid intake

Place patient on a bed rest

The GI tract is the most usual source of bleeding of its mucosal fragility

To prevent other complications

To prevent risk for hemorrhage

Indicators of anemia, active bleeding or impending complications

To prevent dehydration

To detect further existing discomfort

Patient condition improved

Generic Name

Brand Name

Classification Mechanism of action

Dosage Indication Contraindication Adverse Effect Nursing Responsibilities

PARACETAOMOL

BIOGESIC

Anti-pyretic Lessens the core temperature of the body

Syrup5ml every four hours

Symptomaticrelief of pain andfever.

· Contraindicated in patientshypersensitive to drug.· Use cautiously in patients with longterm alcohol use because therapeuticdoses cause hepatotoxicity in thesepatients.

· Hematologic: hemolytic anemia,neutropenia, leucopenia, pancytopenia.· Hepatic: Jaundice· Metabolic: Hypoglycemia· Skin: rash, urticaria.

Use liquid form for children andpatients who have difficultyswallowing.· In children, don’t exceed five dosesin 24 hours.· Advise patient that drug is only forshort term use and to consult thephysician if giving to children forlonger than 5 days or adults forlonger than 10 days.· Advise patient or caregiver thatmany over the counter productscontain acetaminophen; be awareof this when calculating total dailydose.· Warn patient that high doses orunsupervised long term use cancause liver damage.

IX. DRUG STUDY

Generic Name

Brand Name

Classification Mechanism of action

Dosage Indication Contraindication Adverse Effect

Nursing Responsibilities

AMPICILLIN

PAMECIL

Antibiotic Ampicillin exerts bactericidal action on both gm+ve and gm-ve organisms. Its spectrum includes gm+ve organisms eg, S pneumoniae and other Streptococci, L monocytogenes and gm-ve bacteria eg, M catarrhalis, N gonorrhoea, N meningitidis, E coli, P mirabilis, Salmonella, Shigella, and H influenzae. Ampicillin exerts its action by inhibiting the synthesis of bacterial cell wall.

460 mg via IV

For susceptible infections

Hypersensitivity; infectious mononucleosis.

GI upset, nausea, vomiting, diarrhoea; blood dyscrasias; urticaria, exfoliative dermatitis, rash; fever, seizures; interstitial nephritis.

Should administer the medication using aseptic technique

Monitor if there is side effect.

Discontinued if there are any reactions.

X. HEALTH TEACHINGS

M Advise the relatives of the patient to continue the prescribed home medication ordered by the physician

E Provide a clean environment Avoid heavily polluted areas Use of screens when sleeping Avoid having stocked water on a container without cover in your house.

T Advise the patient to increase intake of fluids Instruct to have enough rest at home

H Advise to put some insect repellants Maintain good hygiene by daily taking a bath.

O Instruct to continue consulting to a doctor as ordered.

D Eat healthy foods such as fruits, meats and vegetables Drink plenty of water at least 8-10 glasses of water a day

S Advise family not to go to places with dirty surroundings to prevent possible source of infection.

XI. EVALUATION

This case study enables the students to identify and determine the general health problems and needs of the patient with an admitting diagnosis of dengue fever. It also help patient to promote health and medical understanding of such condition. This also help student to gain more knowledge, skills and attitude. This will present as a reference to student and readers.