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Transcript of Dengue Case Study1
University of Makati
College of NursingJ.P. Rizal Extension, West Rembo Makati City
A Case Study on
Dengue Hemorrhagic Fever
In partial fulfillment of the requirements in
Maternal and Child Nursing 2
Submitted to
Professor Kathlyn Elizabeth Santiago
Submitted by
Johnson BainganCatherine CalimlimJanice Pola Congzon
Ma. Theresa DimaculanganDean Fornea
Erlyn RegondonRonaldo Zamora
September 2008
A C K N O W L E D G M E N T
First of all, we would like to thank the Almighty God for the enlightenment
and strength He has bestowed on us in doing this case study.
We would like to acknowledge the following people:
To Ms. Kathleen Elizabeth Santiago for being one of our mentors;
To Mr. Edgar Clariz, for allowing us to review the medical records of our
patient; and
To our group, for the effort and a job well done!
TABLE OF CONTENTS
I INTRODUCTION............................................................................1
II OBJECTIVE....................................................................................4
III ANATOMY AND PHYSIOLOGY........................................................5
IV DENGUE AND DENGUE HEMORRHAGIC FEVER..........................10
V PATHOPHYSIOLOGY...................................................................16
VI COMPREHENSIVE HEALTH HISTORY...........................................27
VII PHYSICAL ASSESSMENT.............................................................29
VIII DIAGNOSTICS AND LABORATORY EXAMS..................................32
IX MEDICAL MANAGEMENT............................................................42
X COURSE IN THE WARD
…………………………………………………………… 44
XI DRUG ANALYSIS.........................................................................46
XII NURSING CARE PLAN.................................................................49
XIII HEALTH TEACHING.....................................................................58
I. INTRODUCTION
Dengue infection is one of the most common mosquito borne viral diseases of
public health significance. It has been identified as a clinical entity since
1780. Dengue is found in tropical and sub-tropical regions around the world,
predominantly in urban and semi-urban areas. Dengue hemorrhagic fever
(DHF), a potentially lethal complication, was first recognized in the 1950s
during the dengue epidemics in the Philippines and Thailand, but today DHF
affects most Asian countries and has become a leading cause of
hospitalization and death among children in several of them where in age
groups that are predominantly affected are the preschool and school age.
This is a case of a 3 year-old male with Dengue Hemorrhagic Fever Category
II. Patient X is a toddler, admitted into the hospital around 5:00 am carried
by his mother. He is crying, looks weak and was not able to sleep well prior
to his admission, having eyebags are evidence of his restlessness. His mother
had told to the nurse that his child had already vomited three times before he
was brought to the hospital.
Doctors have diagnosed Patient X with DHF II with accompanying acute
tonsilopharyngitis. The patient tonsils were reddened and slightly inflamed
due to his tonsilphayringitis with a high fever measuring 40.5 oC. Patient’s
breath sounds were clear and no signs of dehydration as evidence by good
skin turgor. Rashes were not present on either extremities or on his body
area.
To support the doctors diagnosis of Dengue, his Attending Physician ordered
complete blood count, platelet count, blood typing, stool examination and
urinalysis. At this time the patient was already on IVF as part of his fluid
replacement therapy since he had vomited three times before his admission
and this also serve as his initial treatment to his diagnosis.
Patient X temperature was closely monitored during his 6 day stay in the
hospital. His first 3 days was a period of high-fever, a classic symptom of
Dengue Fever in its Febrile stage. On his first day, the patient had a
convulsive state due to his elevated fever. Frequent tepid sponge bath were
given to him, two to four times in an eight hour shift, in conjunction with his
anti-pyretic drug medication to relieve him from his discomfort brought by his
high temperature. Anti-biotics was also part of his medication to treat his
tonsilopharyngitis. Within his first three day stay, patient is irritable most of
time, restless and crying. Patient X seldom ate the foods served to him. On
his fourth day, a significant drop in his temperature was noted, as low as 36.8 oC which is a sign that the patient is entering into the toxic stage of Dengue
Fever. This state of defervescence, is a period where the number of patient’s
platelet is at its lowest. It is at this time where his attending physician
ordered another Laboratory request for CBC and PC to check if Patient X’s
platelet count is below the normal range of 150,000 to 350,000/L, which is
referred to as thrombocytopenia. The laboratory request was done in
anticipation of a possible bleeding episode where blood transfusion or
platelet transfusion will be administered. Frank bleeding is a worst case
scenario for a patient suffering from DHF. Laboratory test results is not
indicative of platelet count below 20,000 /L which would place the patient a
candidate for hemorrhagic bleeding.
After the significant drop of the client’s temperature, Patient X temperature
were elevated again for eight hours, a normal phenomenon for a DHF patient
before entering into the convalescent stage. His fifth day up to his seventh
day stay in the pediatric ward was a period of recuperation. Patient X’s
Attending Physician noted the appearance of Herman’s rash on his sixth day,
which is an indication that the patient is fully recovering since a rash after the
period of toxic stage is common to a patient suffering from DHF.
The patient was discharged on the seventh day with a resolving Dengue
Hemorrhagic Fever as his final diagnosis.
DENGUE HEMORRHAGIC FEVER 2
Dengue is an important differential diagnosis of fever in children and adults
presenting to first-level health facilities in tropical Asia and Latin America.
Dengue is not included in the generic Integrated Management of Childhood
Illnesses (IMCI) algorithm, but due to its importance, it was incorporated in
several Asian and Latin American IMCI adaptations. Most of these adaptations
have not been tested for their performance.
Prior to and in parallel with IMCI, there have been guidelines develop, on the
management of dengue. The “Guidelines for Treatment of Dengue
Fever/Dengue Hemorrhagic Fever in Small Hospitals” develop by the WHO
Regional Office is widely used. There has been no previous summary of
existing dengue guidelines to explore their usefulness in the context of IMCI
and to identify questions for research.
Dengue cases have become a normal occurrence at this time of the year and
it is always safe to remind people continuously about the danger of this
disease. This case study aims to identify and determine the general health
problems and needs of the patient with an admitting diagnosis of dengue
hemorrhagic fever. This presentation also intends to help patient promote
health and medical understanding of such condition through the application
of nursing skills. Moreover, paper is also intended to provide a better
understanding of the disease process based on the patient’s health history
and as a reference for future nursing students.
DENGUE HEMORRHAGIC FEVER 3
II. OBJECTIVESGeneral objective
This case study aims to identify and determine the general health problems
and needs of the patient with an admitting diagnosis of dengue hemorrhagic
fever. This presentation also intends to help patient promote health and
medical understanding of such condition through the application of nursing
skills. This paper is also intended to provide a better understanding of the
disease process based on the patient’s health history and as a reference for
future nursing students.
Specific Objectives
To raise the level of awareness of patient and family on health
problems that they may encounter
To facilitate the patient and family in taking necessary actions to
solve and prevent the identified problems on her own
To trace the disease process as well as possible etiologies.
To render nursing care and information to patient through the
application of the nursing skills.
To create a nursing care plan for individualized care of the
patient.
DENGUE HEMORRHAGIC FEVER
III. ANATOMY AND PHYSIOLOGY
HEMATOLOGIC SYSTEM
The hematologic system consists of the blood and the sites where blood is
produced, including the bone marrow and the reticuloendothelial system
(RES). Blood is a specialized organ that differs from other organs in that it
exists in a fluid state. Blood iscomposed of plasma and various types of cells.
Plasma is the fluid portion of blood; it contains various proteins, such as
albumin, globulin, fibrinogen, and other factors necessary for clotting, as well
as electrolytes, waste products, and nutrients. About 55% of blood volume is
plasma.
BLOOD
The cellular component of blood
consists of three primary cell types :
RBCs (red blood cells or
erythrocytes), WBCs (white blood
cells or leukocytes), and platelets
(thrombocytes). These cellular
components of blood normally make
up 40% to 45% of the blood volume.
Because most blood cells have a
short life span, the need for the body
to replenish its supply of cells is
continuous; this process is termed
hematopoiesis. The primary site for
hematopoiesis is the bone marrow.
During embryonic development and
in other conditions, the liver and spleen may also be involved. Under normal
conditions, the adult bone marrow produces about 175 billion RBCs, 70 billion
neutrophils (mature form of a WBC), and 175 billion platelets each day. When
DENGUE HEMORRHAGIC FEVER
the body needs more blood cells, as in infection (when WBCs are needed to
fight the invading pathogen) or in bleeding (when more RBCs are required),
the marrow increases its production of the cells required. Thus, under normal
conditions, the marrow responds to increased demand and releases adequate
numbers of cells into the circulation.
The volume of blood in humans is approximately 7% to 10% of the normal
body weight and amounts to 5 to 6 L. Circulating through the vascular system
and serving as a link between body organs, the blood carries oxygen
absorbed from the lungs and nutrients absorbed from the gastrointestinal
tract to the body cells for cellular metabolism. Blood also carries waste
products produced by cellular metabolism to the lungs, skin, liver, and
kidneys, where they are transformed and eliminated from the body. Blood
also carries hormones, antibodies, and other substances to their sites of
action or use.
Blood is made up of plasma (fluid component) and formed elements (cellular
component). Plasma consists of about 90% water and 10% solutes
(electrolytes, albumin, globulins, and clotting factors). The formed elements
include erythrocytes (red blood cells [RBCs]), leukocytes (white blood cells
[WBCs]), and platelets (PLTs).
To function, blood must remain in its
normally fluid state. Because blood
is fluid, the danger always exists that
trauma can lead to loss of blood
from the vascular system. To
prevent this, an intricate clotting
mechanism is activated when
necessary to seal any leak in the
blood vessels. Excessive clotting is
equally dangerous, because it can
obstruct blood flow to vital tissues.
To prevent this, the body has a fibrinolytic mechanism that eventually
dissolves clots (thrombi) formed within blood vessels. The balance between
DENGUE HEMORRHAGIC FEVER
these two systems, clot (thrombus) formation and clot (thrombus) dissolution
or fibrinolysis, is called hemostasis.
BONE MARROW
The bone marrow is the site of hematopoiesis, or blood cell formation. In a
child all skeletal bones are involved, but as the child ages marrow activity
decreases. By adulthood, marrow activity is usually limited to the pelvis, ribs,
vertebrae, and sternum. Marrow is one of the largest organs of the body,
making up 4% to 5% of total body weight. It consists of islands of cellular
components (red marrow) separated by fat (yellow marrow). As the adult
ages, the proportion of active marrow is gradually replaced by fat; however,
in the healthy person, the fat can again be replaced by active marrow when
more blood cell production is required. In
adults with disease that causes marrow destruction, fibrosis, or scarring, the
liver and spleen can also resume production of blood cells by a process
known as extramedullary hematopoiesis. The marrow is highly vascular.
Within it are primitive cells called stem cells. The stem cells have the ability
to self-replicate, thereby ensuring a continuous supply of stem cells
throughout the life cycle. When stimulated to do so, stem cells can begin a
process of differentiation into either myeloid or lymphoid stem cells. These
stem cells are committed to produce specific types of blood cells. Lymphoid
stem cells produce either T or B lymphocytes.Myeloid stem cells differentiate
into three broad cell types: RBCs,WBCs, and platelets. Thus, with the
exception of lymphocytes, all blood cells are derived from the myeloid stem
cell. A defect in the myeloid stem cell can cause problems not only with WBC
production but also with RBC and platelet production. The entire process of
hematopoiesis is highly complex.
PLATELETS (THROMBOCYTES)
Platelets, or thrombocytes, are not actually cells. Rather, they are granular
fragments of giant cells in the bone marrow called megakaryocytes. Platelet
DENGUE HEMORRHAGIC FEVER
production in the marrow is regulated in part by the hormone
thrombopoietin, which stimulates the production and differentiation of
megakaryocytes from the myeloid stem cell. Platelets play an essential role
in the control of bleeding. They circulate freely in the blood in an inactive
state, where they nurture the endothelium of the blood vessels, maintaining
the integrity of the vessel. When vascular injury does occur, platelets collect
at the site and are activated. They adhere to the site of injury and to each
other, forming a platelet plug that temporarily stops bleeding. Substances
released from platelet granules activate coagulation factors in the blood
plasma and initiate the formation of a stable clot composed of fibrin, a
filamentous protein. Platelets have a normal life span of 7 to 10 days.
PLASMA AND PLASMA PROTEINS
After cellular elements are removed from blood, the remaining liquid portion
is called plasma. More than 90% of plasma is water. The remainder consists
primarily of plasma proteins, clotting factors (particularly fibrinogen), and
small amounts of other substances such as nutrients, enzymes, waste
products, and gases. If plasma is allowed to clot, the remaining fluid is called
serum. Serum has essentially the same composition as plasma, except that
fibrinogen and several clotting factors have been removed in the clotting
process. Plasma proteins consist primarily of albumin and globulins. The
globulins can be separated into three main fractions—alpha, beta, and
gamma—each of which consists of distinct proteins that have different
functions. Important proteins in the alpha and beta fractions are the transport
globulins and the clotting factors that are made in the liver. The transport
globulins carry various substances in bound form around the circulation. For
example, thyroid-binding globulin carries thyroxin, and transferrin carries
iron. The clotting factors, including fibrinogen, remain in an inactive form in
the blood plasma until activated by the clotting cascade. The gamma globulin
fraction refers to the immunoglobulins, or antibodies. These proteins are
produced by the well-differentiated lymphocytes and plasma cells. The actual
fractionation of the globulins can be seen on a specific laboratory test (serum
protein electrophoresis). Albumin is particularly important for the
maintenance of fluid balance within the vascular system. Capillary walls are
DENGUE HEMORRHAGIC FEVER
impermeable to albumin, so its presence in the plasma creates an osmotic
force that keeps fluid within the vascular space. Albumin, which is produced
by the liver, has the capacity to bind to several substances that are
transported in plasma (eg, certain medications, bilirubin, some hormones).
People with poor hepatic function may have low concentrations of albumin,
with a resultant decrease in osmotic pressure and the development of
edema.
DENGUE HEMORRHAGIC FEVER
IV. DENGUE and DENGUE HEMORRHAGIC FEVER
Overview
Dengue infection is one of the most common mosquito borne viral diseases of
public health significance. It has been identified as a clinical entity since
1780. Clinical descriptions of the Australian outbreak in 1897 reported that
30 children died. The clinical manifestations of dengue infection range from
asymptomatic infection to undifferentiated fever, an influenza-like symptom
known as dengue fever, and a severe, sometimes fatal disease characterized
by hemorrhage and shock known as dengue hemorrhagic fever (DHF). The
first and second epidemics of DHF occurred in Manila in 1954 and 1956,
followed by the third in Bangkok in 1958. Since then, DHF has spread
throughout tropical Asian countries and has expanded globally.
Dengue viruses, single stranded RNA viruses of the family Flaviviridae, are
the most common cause of arboviral disease in the world. They are found
virtually throughout the tropics and cause an estimated 50-100 million
illnesses annually, including 250,000 - 500,000 cases of dengue hemorrhagic
fever a severe manifestation of dengue and 24,000 deaths. More than two
fifths of the world's population (2.5billion) lives in areas potentially at risk for
dengue. Because travelers to endemic areas are also at risk, healthcare
providers should have an understanding of the spectrum of infection, how to
diagnose it, and what the appropriate treatment is.
Dengue infection is caused by any of four dengue virus serotypes. The clinical
manifestations range from asymptomatic infection to undifferentiated fever,
dengue fever and dengue hemorrhagic fever (DHF). DHF is characterized by
sustained high fever for 2–7 days; bleeding diathesis such as positive
tourniquet test, petechiae, epistaxis and hematemesis; thrombocytopenia
with platelet counts less than 100 x 109 L and plasma leakage due to
increased vascular permeability evidenced by hemoconcentration, pleural
effusion and ascites. Bleeding diathesis is caused by vasculopathy,
thrombocytopenia, platelet dysfunction and coagulopathy. The three stages
of clinical presentations are classified as febrile, toxic and convalescent. The
DENGUE HEMORRHAGIC FEVER
toxic stage, which lasts 24–48 hours, is the most critical period, with rapid
plasma leakage leading to circulatory disturbance. The severity of DHF varies
from mild (World Health Organization grades I and II), with minimal and
transient change in vital signs, to severe (World Health Organization grades
III and IV), with threatened shock (e.g. blood pressure 100/90 mmHg) or
profound shock. There is no specific treatment for DHF. Intensive supportive
care is the most important aspect of management. Early recognition of the
disease and careful monitoring for circulatory disturbance are essential.
Optimal fluid therapy to maintain the functions of the vital organs during the
critical period and effective control of bleeding episodes will lead to favorable
outcomes. Administration of recombinant activated factor VII is suggested
whenever massive bleeding does not respond to blood component therapy.
SOCIO-DEMOGRAPHIC PROFILE
Dengue is a mosquito-borne infection which in recent years has become a
major international public health concern. Dengue is found in tropical and
sub-tropical regions around the world, predominantly in urban and semi-
urban areas.
Dengue hemorrhagic fever (DHF), a potentially lethal complication, was first
recognized in the 1950s during the dengue epidemics in the Philippines and
Thailand, but today DHF affects most Asian countries and has become a
leading cause of hospitalization and death among children in several of them.
An outbreak of dengue fever occurred in Cebu City from August 1987 to
January 1988. A total of 752 cases were hospitalized; 269 records were
reviewed, 20 patients were interviewed, and 18 blood samples were
collected. The majority of the cases were from urban areas. Seventy percent
of the cases were aged 10 years and younger. Fifty-three percent were
classical dengue fever; 22% Grade I; 21% Grade II; and 7% Grade III. There
were three deaths; the case fatality ratio was 0.4%. Three of the 18 blood
samples grew dengue virus serotype 1.
There are four distinct, but closely related, viruses that cause dengue.
Recovery from infection by one provides lifelong immunity against that
serotype but confers only partial and transient protection against subsequent
DENGUE HEMORRHAGIC FEVER
infection by the other three. There is good evidence that sequential infection
increases the risk of more serious disease resulting in DHF.
Prevalence
The global prevalence of dengue has grown dramatically in recent decades.
The disease is now endemic in more than 100 countries in Africa, the
Americas, the Eastern Mediterranean, South-east Asia and the Western
Pacific. South-east Asia and the Western Pacific are most seriously affected.
Before 1970 only nine countries had experienced DHF epidemics, a number
that had increased more than four-fold by 1995.
Some 2500 million people -- two fifths of the world's population -- are now at
risk from dengue. WHO currently estimates there may be 50 million cases of
dengue infection worldwide every year.
In 2001 alone, there were more than 609 000 reported cases of dengue in the
Americas, of which 15 000 cases were DHF. This is greater than double the
number of dengue cases which were recorded in the same region in 1995.
Not only is the number of cases increasing as the disease is spreading to new
areas, but explosive outbreaks are occurring. In 2001, Brazil reported over
390 000 cases including more than 670 cases of DHF.
Some other statistics:
During epidemics of dengue, attack rates among susceptible are often 40 --
50%, but may reach 80 -- 90%.
An estimated 500 000 cases of DHF require hospitalization each year, of
whom a very large proportion are children. At least 2.5% of cases die,
although case fatality could be twice as high.
Without proper treatment, DHF case fatality rates can exceed 20%. With
modern intensive supportive therapy, such rates can be reduced to less than
1%.
The spread of dengue is attributed to expanding geographic distribution of
the four dengue viruses and of their mosquito vectors, the most important of
which is the predominantly urban species Aedes aegypti. A rapid rise in urban
populations is bringing ever greater numbers of people into contact with this
vector, especially in areas that are favorable for mosquito breeding, e.g.
DENGUE HEMORRHAGIC FEVER
where household water storage is common and where solid waste disposal
services are inadequate.
Clinical Presentation
Dengue fever is a severe, flu-like illness that affects infants, young children
and adults, but seldom causes death.
The clinical features of dengue fever vary according to the age of the patient.
Infants and young children may have a non-specific febrile illness with rash.
Older children and adults may have either a mild febrile syndrome or the
classical incapacitating disease with abrupt onset and high fever, severe
headache, pain behind the eyes, muscle and joint pains, and rash.
The three stages of clinical presentation are named febrile, toxic
(hemorrhagic stage) and convalescent. The patients initially develop an
abrupt onset of high fever (39–40 °C) with malaise, headache, nausea,
vomiting, myalgia and, sometimes, abdominal pain. During the acute febrile
stage, which lasts 2–7 daysb (from DOH it is within the first 4 days),
hemorrhagic manifestation is invariably present but usually mild. Petechial
hemorrhage on the skin is commonly found. Also, a positive tourniquet test is
frequently observed. Bleeding at the nose, gastrointestinal tract (manifested
by abdominal pain) and gums is relatively less common compared with
petechiae, but may be severe. Flushing which may be accompanied by
vomiting, conjuctival infection and epistaxis may be observed at a later
period. Recently, menorrhagia has been more prevalent because of the
increasing number of affected adolescents. However, hematuria is extremely
rare. Hepatomegaly is commonly found, and the liver is usually soft and
tender. Thrombocytopenia and rising hematocrit due to plasma leakage are
usually detectable before the onset of the subsequent toxic stage. An abrupt
fall to normal or subnormal levels of temperature, varying degrees of
circulatory disturbance will develop, known as the toxic stage, lasts 24–48
hours. Ultimately, the majority of patients have rapid uneventful recovery
without sequelae in the convalescent stage.
DENGUE HEMORRHAGIC FEVER
Dengue hemorrhagic fever is a potentially deadly complication that is
characterized by high fever, hemorrhagic phenomena--often with
enlargement of the liver--and in severe cases, circulatory failure. The illness
commonly begins with a sudden rise in temperature accompanied by facial
flush and other non-specific constitutional symptoms of dengue fever. The
fever usually continues for two to seven days and can be as high as 40-41°C,
possibly with febrile convulsions and hemorrhagic phenomena.
In moderate DHF cases, all signs and symptoms abate after the fever
subsides. In severe cases, the patient's condition may suddenly deteriorate
after a few days of fever; the temperature drops, followed by signs of
circulatory failure, and the patient may rapidly go into a critical state of shock
and die within 12-24 hours, or quickly recover following appropriate volume
replacement therapy.
Diagnostic Criteria
The clinical diagnosis of DHF is based on four major characteristic
manifestations:
(i) sustained high fever lasting 2–7 days;
(ii) hemorrhagic tendency such as a positive tourniquet test, petechiae or
epistaxis;
(iii) thrombocytopenia (platelet count less than 100 x 109 /L); and
(iv) evidence of plasma leakage manifested by hemoconcentration (an
increase in hematocrit greater than 20% above average for age, sex
and population), pleural effusion and ascites.
Close observation, serial hematocrit and daily platelet count monitoring are
suggested in order to accomplish the clinical diagnostic criteria. Pleural
effusion can be demonstrated by a chest X-ray in right lateral decubitus view
at 12–24 hours after defervescence. These applications may be problematic
in a busy pediatric practice in a dengue-endemic area. A study in Vietnam
suggested to use fever and hemoconcentration together with either bleeding
or thrombocytopenia as clinical criteria of DHF. However, some patients with
bleeding or anemia will not have a rising hematocrit. Therefore, the minimal
criteria should include fever and evidence of plasma leakage together with
either bleeding or thrombocytopenia. Further evaluation in a large
DENGUE HEMORRHAGIC FEVER
prospective series from other dengue-endemic regions is warranted. The
severity of DHF is categorized into four grades: grade I, without overt
bleeding but positive for tourniquet test; grade II, with clinical bleeding
diathesis such as petechiae, epistaxis and hematemesis; grade III, circulatory
failure manifested by a rapid and weak pulse with narrowing pulse pressure
( less than 20 mmHg) or hypotension, with the presence of cold clammy skin
and restlessness; and grade IV, profound shock in which pulse and blood
pressure are not detectable.
DENGUE HEMORRHAGIC FEVER
V. PATHOPYSIOLOGY
Etiologic agent
Dengue viruses’ type 1, 2, 3, & 4
Alternative Names
Hemorrhagic dengue; Dengue shock syndrome; Philippine hemorrhagic fever;
Thai hemorrhagic fever; Singapore hemorrhagic fever
Definition/Transmission
Dengue hemorrhagic fever is a severe, potentially deadly infection bite by
certain mosquitoes (Aedes aegypti ). Day biting female mosquito that breeds
in the household or standing clean water.
Dengue viruses are transmitted to humans through the bites of infective
female Aedes mosquitoes. Mosquitoes generally acquire the virus while
feeding on the blood of an infected person. After virus incubation for 8-10
days, an infected mosquito is capable, during probing and blood feeding, of
transmitting the virus, to susceptible individuals for the rest of its life.
Infected female mosquitoes may also transmit the virus to their offspring by
transovarial (via the eggs) transmission, but the role of this in sustaining
transmission of virus to humans has not yet been delineated.
Humans are the main amplifying host of the virus, although studies have
shown that in some parts of the world monkeys may become infected and
perhaps serve as a source of virus for uninfected mosquitoes. The virus
circulates in the blood of infected humans for two to seven days, at
approximately the same time as they have fever; Aedes mosquitoes may
acquire the virus when they feed on an individual during this period.
Incubation Period
Uncertain, Probably 6 days to one week.
DENGUE HEMORRHAGIC FEVER
Period of Communicability
Unknown. Presumed to be on the first week of illness when virus is still
present in the blood.
Susceptibility, Resistance and Occurence
All persons are susceptible. Both sexes are equally affected. Age groups
predominantly affected are the preschool and school age. Adults and infants
are not exempted. Peak age affected 5-9 years of age.
Occurrence is sporadic throughout the year. Epidemic usually occur during
the rainy season as June – November. Peak months are September and
October.
Susceptibility is universal. Acquired immunity may be temporary but usually
permanent.
Causes
Four different dengue viruses have been shown to cause dengue hemorrhagic
fever. This condition occurs when a person catches a different dengue virus
after being infected by another type sometime before. Prior immunity to a
different dengue virus type plays an important role in this severe disease.
Worldwide, more than 100 million cases of dengue fever occur every year. A
small number of these develop into dengue hemorrhagic fever. Most
infections in the United States are brought in from other countries. It is
possible for a traveler who has returned to the United States to pass the
infection to someone who has not traveled.
Risk factors for dengue hemorrhagic fever include having antibodies to
dengue virus from prior infection and being younger than 12, female, or
Caucasian.
Pathogenesis
The pathogenesis of DHF is poorly understood. DHF caused by primary or
secondary dengue infection is due to the occurrence of abnormal immune
response involving production of cytokines or chemokines, activation of T-
lymphocytes and disturbance of the hemostatic system. upon the second
infection with a heterotypic dengue virus, the subneutralizing concentration
DENGUE HEMORRHAGIC FEVER
of the cross-reacting antibody from the previous infection may opsonize the
virus and enhance its uptake and replication in the macrophage or
mononuclear cells. Secondary infection with a heterotypic dengue virus is
associated with increased risk of developing DHF in individuals who have
recovered from a primary dengue virus with a first serotype. The level of T-
cell activation in a secondary dengue infection is also enhanced, occurring as
a phenomenon known as original antigenic sin, and is undergoing
programmed cell death. Many denguespecific T-cells are of low affinity for the
infected virus and show higher affinity for other, probably previously
encountered serotypes. Profound T-cell activation and death during acute
dengue infection may suppress or delay viral elimination, leading to the
higher viral loads and increased immunopathology found in patients with DHF
Symptoms
Early symptoms of dengue hemorrhagic fever are similar to those of dengue
fever, but after several days the patient becomes irritable, restless, and
sweaty. These symptoms are followed by a shock-like state.
Bleeding may appear as pinpoint spots of blood on the skin (petechiae) and
larger patches of blood under the skin (ecchymoses). Bleeding may occur
from minor injuries. Shock may cause death. If the patient survives, recovery
begins after a one-day crisis period.
Early symptoms include the following:
Fever
Headache
Muscle aches
Joint aches
Malaise
Decreased appetite
Vomiting
Acute phase symptoms include the following:
Shock-like state
Sweaty (diaphoretic)
Cold, clammy extremities
Restlessness followed by:
o Worsening of earlier symptoms
DENGUE HEMORRHAGIC FEVER
o Petechiae
o Ecchymosis
o Generalized rash
The severity of DHF is categorized into four grades: grade I, without overt
bleeding but positive for tourniquet test; grade II, with clinical bleeding
diathesis such as petechiae, epistaxis and hematemesis; grade III, circulatory
failure manifested by a rapid and weak pulse with narrowing pulse pressure
( less than 20 mmHg) or hypotension, with the presence of cold clammy skin
and restlessness; and grade IV, profound shock in which pulse and blood
pressure are not detectable.
Category I Category II Category III Category IV
History or presence of fever 2-7 days duration, with a (+) tourniquet test or presence of skin flushing or petechial rash
Category I plus Presence of one or more Danger Signs (especially defervescence)RestlessnessChanges in sensoriumCold, clammy skinSudden onset of abdominal painDifficulty of breathingCircumoral cyanosisSeizuresSpontaneous bleeding (gum bleeding, epistaxis, rashes, petechiae)
Category II plus Circulatory failureCold clammy skinWeak thready pulseNarrow pulse pressure ( less than 20mm/Hg)HypotensionRestlessness
Category III plus profound shock with undetectable pulse and blood pressure
Evidence of plasma leakage
The plasma leakage is due to the increased vascular permeability induced by
several mediators such as C3a, C5a during the acute febrile stage and
prominent during the toxic stage. The evidence of plasma leakage includes
hemoconcentration, hypoproteinemia/hypoalbuminemia, pleural effusion,
ascites, threatened shock and profound shock. The rising hematocrit may not
be evidenced because of either severe bleeding or early intravenous fluid
replacement.
DENGUE HEMORRHAGIC FEVER
Bleeding tendency
The bleeding diathesis is caused by vasculopathy, thrombocytopenia, platelet
dysfunction and coagulopathy.
Vasculopathy
A positive tourniquet test indicating the increased capillary fragility is found
in the early febrile stage. It may be a direct effect of dengue virus as it
appears in the first few days of illness during the viremic phase.
Thrombocytopenia and platelet dysfunction.
Patients with DHF usually have platelet counts less than 100 x 109/L.
Thrombocytopenia is most prominent during the toxic stage. The
mechanisms of thrombocytopenia include decreased platelet production and
increased peripheral destruction. The increased peripheral destruction is
markedly prominent during 2 days before defervescence. The bone marrow
then revealed hypercellularity with an increase in the megakaryocyte,
erythroblast and myeloid precursors. Hemophagocytosis of young and
mature erythroid and myeloid cells, lymphocytes and platelets was observed
Subsequently, the number of platelets is rapidly increased in the
convalescent stage and reaches the normal level within 7–10 days after the
defervescence.
Platelet dysfunction as evidenced by the absence of adenosine diphosphate
(ADP) release was initially demonstrated in patients with DHF during the
convalescent stage. The subsequent study during the febrile and early
convalescent stages by Srichaikul et al. in 1989 also demonstrated the
impaired platelet aggregation response to ADP that returned to a normal
response 2–3 weeks later. An increase in plasma - thromboglobulin and
platelet factor 4, indicating increased platelet secretory activity, was
observed. The platelet dysfunction might be the result of exhaustion from
platelet activation triggered by immune complexes containing dengue
antigen.
Coagulopathy
DENGUE HEMORRHAGIC FEVER
During the acute febrile stage, mild prolongation of the prothrombin time and
partial thromboplastin time, as well as reduced fibrinogen levels, have been
demonstrated in several studies. Variable reductions in the activities of
several coagulation factors, including prothrombin, factors V, VII, VIII, IX and
X, antithrombin and antiplasmin, have been demonstrated. Fibrin
degradation product or D-dimer is slightly elevated. Low levels of
anticoagulant proteins C and S and antithrombin III were found to be
associated with increasing severity of shock, presumably due to plasma
leakage. Elevated levels of tissue factor, thrombomodulin and plasminogen
activator inhibitor-1 reflect endothelial, platelet and/or monocyte activation
and may be a secondary response to direct activation of fibrinolysis by the
dengue virus. The coagulation abnormality is well compensated for in the
majority of patients without circulatory collapse. Most of the patients have
serum aspartate transaminase (AST) and alanine transaminase (ALT) levels
three and twofold higher than normal, respectively. There is focal necrosis of
hepatic cells, swelling appearance of Councilman bodies and hyaline necrosis
of Kupffer cells. Proliferation of mononuclear leucocytes and less frequently
polymorphonuclear leucocytes occurs in the sinusoids and occasionally in the
portal areas.
Possible Complications:
Shock
Encephalopathy
Residual brain damage
Seizures
Liver damage
DENGUE HEMORRHAGIC FEVER
Diagnostic Procedure
Physical examination may reveal the following:
Low blood pressure
A weak, rapid pulse
Rash
Red eyes
Red throat
Swollen glands
Enlarged liver
(hepatomegaly)
Tests may include the following
Hematocrit
Platelet count
Electrolytes
Coagulation studies
Liver enzymes
Tourniquet test (capillary fragility test or Rumpel Leads test) a
presumptive test which is positive in the presence of more than 20
petechiae within an inch square, after 5 minutes of test.
Inflate BP cuff on upper arm to a point midway between the systolic
and diastolic pressure of 5 min
Release cuff and make an imaginary 1square inch just below the cuff,
at the antecubital fossa
Count the number of petechiae inside the box
DENGUE HEMORRHAGIC FEVER
X-ray of the chest (may demonstrate pleural effusion)
Serologic studies (demonstrate antibodies to Dengue viruses)
Serum studies from samples taken during acute illness and
convalescence (increase in titer to Dengue antigen)
Get baseline platelet count and hematocrit; repeat daily if platelet
count is <100,000/uL
Take serial platelet count and hematocrit 1-3x daily
Monitor vital signs and urine output
Request for blood typing, clotting time and bleeding time
If necessary, do chest x-ray to assess pleural effusion, ECG for
myocarditis, or ABGs for metabolic acidosis
Optional: prothrombin time, partial thromboplastin time, fibrinogen,
total protein, albumin, globulin
Medical Management
Management Protocol in DHF by Dept. of Health (strategies)
Case diagnosis, management, referral
Health education/Advocacy
Rapid response mosquito control
Research and project development
Integrated vector control
Surveillance
Training
Medical Treatment
Symptomatic and supportive relief
Rapid replacement of Fluids (most important treatment) like oresol
and IV
o Give oresol at 75ml/KBW in 4-6hrs then maintain patient at 1-2L/day; continue giving other types of home fluids.
DENGUE HEMORRHAGIC FEVER
o Start IVF using D5LRS or D5 0.9NaCl or plain LRS:
o Give IVF at 5-7ml/KBW/hr if there is hemoconcentration or signs of plasma leakage. Then reduce IVF rate to 3ml/KBW/hr if there is subsequent improvement. Discontinue IVF after 24-48hrs if child remains stable. Otherwise, IVF may be increased by 3-5ml increments up to 15ml/KBW/hr until there is improvement and as long as patient is not in shock or there is no significant blood loss.
o Give IVF at 10-20ml/KBW IV bolus in <20minutes if patient is in shock; Repeat dose if there is no immediate improvement. Give plasma, plasma substitutes or 5% albumin at 10-20ml/KBW as rapid bolus if hematocrit rises and shock is still present. Give oxygen. Once improvement occurs adjust IVF same as above
o Give fresh whole blood at 1-ml/KBW if there is significant blood loss or if hematocrit continues to fall despite fluid resuscitation. If there is frank, uncontrolled bleeding.
o Give platelets when platelet count is below 150,000/uL or if there is significant blood loss and platelet count is below 150,000/uL, or there is continuous bleeding and hematocrit remains normal.
o Use fresh frozen plasma or cryoprecipitate in DIC. Correct metabolic acidosis
o Give oresol to replace fluid as in moderate dehydration at 75ml/kg in 4-6 hours or up to 2-3L in adults. Continue ORS intake until patients condition improves.
Paracetamol (NO ASPIRIN), for headache give analgesic
Fresh whole blood transfusion is ordered if thrombocytopenia and
platelet declines
For nose bleeding, flex the neck to prevent aspiration. Keep an
elevated position of trunk and promote vasoconstriction in nasal
mucosa membrane through an ice bag over the forehead
For melena, ice bag over the abdomen.
Avoid unnecessary movement
DENGUE HEMORRHAGIC FEVER
Assist in the management of shock. Dorsal recumbent to
trendelenburg position. Dorsal recumbent position facilitates
circulation.
For shock, provide warmth through lightweight covers, (overheating
causes vasodilation which aggravates bleeding)
Monitor vital signs, especially temperature because the critical period
for early signs of shock is the transition from febrile to afebrile phase
Diet: Low fat, low fiber, non irritating, non carbonated, non acidic
food. Noodle soup may be given. No dark colored foods, which can be
mistaken as melena for a dark colored stool.
The following have no role in treatment/or have not been
assessed adequately: Vit. C, steroids, IVIg
Outlook (Prognosis)
With early and aggressive care, most patients recover from dengue
hemorrhagic fever. However, half of untreated patients who go into shock do
not survive
DENGUE HEMORRHAGIC FEVER
VI. COMPREHENSIVE HEALTH HISTORY
Patient X is 2 years and 9 months old a male toddler born and raised from
South Cotabato
Informant: Patient’s mother
Reliability: 100%
Patient: Patient X
Birthday: November 10, 2005
Nationality: Filipino
Address: 271B, 61D, PA. South Cotabato
Type of Admission: Direct from ER
Attending Physician: Dr. X
Final Diagnosis: Dengue Hemorrhagic Fever II
Ward: Pediatric Ward
Hx: This is a case of a 3 year-old male with DHF II
Chief complaint: Fever
HPI:
10 hours PTA - (+) high grade fever, vomiting for several hours
DENGUE HEMORRHAGIC FEVER
Patient History
Patient X is a toddler, admitted into the hospital around 5:00 am carried by
his mother.
He is born healthy, under normal spontaneous vaginal delivery without any
body-marks or observable congenital birth defects. He has completed his
immunization program for the following vaccines: BCG, DPT, OPV, MEASLES
and HEPA-B.
Patient X being the youngest of three 3 siblings, stays with her mother most
of time at home. This is his first time to contact a serious illness since his
birth. Most of the time he frequently catch common colds and slight to
moderate fever but not of a high grade fever. The night prior to his admission
to the hospital, patient X is feverish and it worsens in the wee hours of the
morning. Patient is irritable, crying and has vomited for about three times.
DENGUE HEMORRHAGIC FEVER
VII. PHYSICAL ASSESSMENT
CATEGORY FINDINGS
General Appearance The patient looks weak and with eyebags.
Vital Signs Temperature: 40.5
Respiration: 30 cpm
Pulse Rate: 110
Blood Pressure: 90/40
Skin Upon inspection, the patient was noted to have flushed skin color
Hair The patient’s natural hair color is black. Soft and shiny.
Head/skull Upon inspection the skull is symmetrically aligned. No signs of lesions.
Eyes Eyes and eyebrows are symmetrically aligned with equal distribution of hair on both eyebrows.
PERRLA
Ears The color of both ears is the same with the facial skin and is symmetrically aligned. No ear discharge is noted.
Nose The external nose is symmetric and straight same color as with the facial skin. There is no nasal flaring. No obstruction in both nasal cavities
Lips Appears to be a little bit dry but not bluish or cyanotic. No lesions, cracks or warts are present
Neck The patient can move his head freely, no nodules palpated in the cervical area
Thorax/Lung Normal respiration, symmetrical chest expansion, clear breath sounds, negative retraction.
Heart/Cardiovascular Normal cardiac rate, symmetrical peripheral pulse noted.
Abdomen Normal bowel sound. Soft non tender abdomen
Muscoloskeletal Motor @ 4/5 upper and lower extremities
Both appear to be symmetric
Mental Status Conscious and oriented
DENGUE HEMORRHAGIC FEVER
Head and Neck:
(-) Decreased hearing
(-) Ringing in ears
(-) Frequent ear infections
(-) Dizzy spells
(-) Failing vision
(-) Double vision
(-) Blurred vision
(-) Eye pain
(-) Repeated eye infections
(-) Recurrent nose bleeds
(-) Dental disease
(-) Sinus trouble
(-) Frequent sore throats
(-) Neck swelling
(-) Hay fever
Respiratory
(-) Hoarseness
(-) Persistent cough
(-) Blood in spit
(-) Shortness of breath
Cardiovascular
(-) Chest pain traveling down left arm
(-) Palpitations
(-) Irregular heart beat
(-) Swollen ankles
(-) Fainting spells
(-) Pain in legs when walking
Genitourinary
(-) Painful urination
(-) Blood in urine
(-) Frequent urination
(-) Night time urinary frequency
(-) Loss of control of urine
(-) Decrease in force of urine stream
(-) Sexual dysfunction
DENGUE HEMORRHAGIC FEVER
Endocrine
(-) Chronic fatigue
(-) Weight loss – recent
(-) Bruise easily
(-) Cold extremities
(-) Tremors (shaking of hands)
(-) Convulsions
(+) Muscle weakness
Neurological
(-) Numbness
(-) Tingling sensations
(+) Headaches
(-) Nervousness
(-) Memory Loss
(-) Moodiness
(-) Difficulty falling asleep
(-) Difficulty staying awake
(+) Increased irritability
Musculoskeletal
(-) Neck pain
(-) Joint pain
(-) Low back pain
(-) Foot pain
(-) Stiff joints
Skin
(-) Petechiae rashes
(-) Hives
Past Medical History:
(-) previous hospitalization / OR / accidents
(-) asthma / allergy
DENGUE HEMORRHAGIC FEVER
HEMATOLOGY RESULT
Day 1
Hemoglobin-13.6 M:(13.0-18.0 Cms%) RBC 4.7 M: (4.5-6.5x10 L)
F:(12.0-18.0 Cms%) F: (3.8-5.8x10 L)
C:(11.7-13-0 Cms%) C: (4.0-5.2x10 L)
Hematocrit- 0.41 M:(0.40-0.54 Vol%) WBC---4.7---(4.5-10X10 L)
F:(0.37-0.47 Vol%)
C:(0.32-0.42 Vol%)
Differential Count:
Segmenters-----0.80 (0.50-0.70) Blood Type O+
Lymphocytes---0.20 (0.20-0.40) Bleeding Time----(1-4mins)
Eosinophils------------(0.01-0.05) Clotting Time-----(2-5mins)
Basophils---------------( -0.01 E.S.R M:(0.10mm/hr)
Monocytes--------------( -0.03) F: (0.20mm/hr)
Platelet Count—138 -(150-350 L)
Malarial Smear:_________________________
Others:________________________________
_________________________________ ______________________
(Commanding Officer) (Medical Technologist)
_________________________________ ______________________
(Comanding Officer) (Medical Technologist)
DENGUE HEMORRHAGIC FEVER
The Complete Blood Count is a screening test, used to diagnose and manage
numerous diseases. Test results shows normal value for Lymphocytes.
Eosiniphils Basophils and Monocytes values were not included in the
laboratory result, a marked increased in WBC indicates a positive infection.
Neutrophils/Segmenters are elevated, suggestive of Bacterial infection.
Lymphocytes are responsible for immune responses. An elevation is present
in cases of viral infection, leukemia, cancer of the bone marrow, or radiation
therapy while a decreased lymphocyte level can indicate diseases that affect
the immune system. A significant decrease in lymphocyte value indicates
low immune response.
Hematocrit values are indicators of ratio of RBC in relation to blood volume.
This is best compared with Hemoglobin value since the two values are
indicative of RBC present in the blood. The oxygen-combining ability of the
blood is in direct proportion to the hemoglobin concentration, rather than the
numbers of red blood cells, because some cells contain more hemoglobin
than others. Hemoglobin also serves as an important pH buffer in the
extracellular fluid. Hemoglobin determination is used to screen for anemia, to
identify the severity of anemia, and to assist in evaluating the patient's
response to anemia therapy. While a patient with a platelet count of less than
20,000 is at high risk for spontaneous bleeding.
DENGUE HEMORRHAGIC FEVER
HEMATOLOGY RESULT
Day 4
Hemoglobin-14.3 M:(13.0-18.0 Cms%) RBC 5 M: (4.5-6.5x10 L)
F:(12.0-18.0 Cms%) F: (3.8-5.8x10 L)
C:(11.7-13-0 Cms%) C: (4.0-5.2x10 L)
Hematocrit- 0.43 M:(0.40-0.54 Vol%) WBC---8.2---(4.5-10X10 L)
F:(0.37-0.47 Vol%)
C:(0.32-0.42 Vol%)
Differential Count:
Segmenters-----0.36 (0.50-0.70) Blood Type O+
Lymphocytes---0.64 (0.20-0.40) Bleeding Time----(1-4mins)
Eosinophils------------(0.01-0.05) Clotting Time-----(2-5mins)
Basophils---------------( -0.01) E.S.R M:(0.10mm/hr)
Monocytes--------------( -0.03) F: (0.20mm/hr)
Platelet Count—190 -(150-350 L)
Malarial Smear:_________________________
Others:________________________________
_________________________________ ______________________
(Commanding Officer) (Medical Technologist)
_________________________________ ______________________
(Comanding Officer) (Medical Technologist)
A decrease in neutrophils is known as neutropenia. Although most bacterial
infections stimulate an increase in neutrophils, some bacterial infections such
as typhoid fever and brucelosis and many viral diseases, including hepatitis,
influenza, rubella, rubeola, and mumps, decrease the neutrophil count. An
overwhelming infection can also deplete the bone marrow of neutrophils and
produce neutropenia.
DENGUE HEMORRHAGIC FEVER
URINALYSIS RESULT
Day 1
Physical Appearance
Test Result Normal
Color Yellow Yellow
Transparency Slightly hazy Clear
Reaction PH 6.0 4.6 - 8.0
Specific Gravity 1.030 1.010 – 1.035
Sugar Negative Absent
Protein Negative Absent
Microscopic
Test Result Normal
Pus Cell 0-3 Absent
RBC 0-1 0-5
Epithelial Cells Occasional
Protein Negative Absent
Crystal
Amorphous urates Positive
Amorphous Phosphate Blank
DENGUE HEMORRHAGIC FEVER
Urinalysis can disclose evidence of diseases, even some that have not caused
significant signs and symptoms. The color of urine is normally yellow, but if it
is reddish, this is indicative of presence of blood in the urine. Urine
transparency should be clear. Urine specific gravity measures the
concentration of particles in the urine. Increased urine specific gravity may
indicate dehydration, glycosuria and heart failure. Decreased urine specific
gravity may indicate excessive fluid intake and pyelonephritis. Urine normally
contains no glucose and abnormal results may indicate excessive diabetes
mellitus, renal glycosuria and increase Intra-Cranial Pressure. Protein is
normally not found the urine, specifically albumin. The most common cause
of protein in the urine is glomerular damage from renal disease, renal
distress, cardiac failure and febrile condition. Presence of pus cells can mean
there is kidney disease or an infection of the kidney, bladder or urinary tubes.
The presence of abnormal numbers of white cells in the urine is referred to as
pyuria. Normally there is no hemoglobin or RBC in the urine. RBC in the urine
may be due to many causes including kidney damage, tumors eroding the
urinary tract, stones, UTI and bleeding disorders.
The Appearance of urine, which is slightly turbid indicates infection. This is
even supported by the presence of pus in the urine. Presence of protein
indicates a renal distress. The increased specific gravity signifies dehydration
and glycosuria, supported by presence of glucose in the urine. Any
measurement below 1.007 to 1.010 indicates hydration and any
measurement above it indicates relative dehydration. Urine having a specific
gravity over 1.035 is either contaminated, contains very high levels of
glucose, or the patient may have recently received high density radiopaque
dyes intravenously for radiographic studies or low molecular weight dextran
solutions. Amorphous urates are observed in acidic urines and amorphous
phosphates are found in alkaline urine. The amorphous urates seen in urine
specimens are of little clinical value.
DENGUE HEMORRHAGIC FEVER
FECALYSIS
Day 3
Color: Yellow
Consistency: Soft
Fecalysis result is normal, no dark colored bowel that would indicate GI bleeding.
TYPHIDOT
Day 3
Test Result:
IgG : Positive
IgM : Negative
Interpretation of typhidot test should be based on the result of IgM. A positive IgM is
indicative of typoid fever. Typhidot test can be used as a valid tool in the diagnosis of
typhoid fever among Filipinos but whenever feasible, confirmation with blood cultures is
strongly encouraged especially with the appearance of drug resistant strains in the
community. A valid conclusion can be made from a single sample based on results of
IgM titer. Typhidot offers the advantage of speed, simplicity and early diagnosis.
DENGUE HEMORRHAGIC FEVER
SUMMARY OF LABORATORY RESULTS
Laboratory Exams Day 1 Day 3 Day 4 Normal ValuesHematology Resut Hemoglobin 13.6 14.3 13.0 - 18.0 Cms%Hematocrit 0.41 0.43 0.40 - 0.54 Vol%RBC 4.7 5 4.5 - 6.5x10 LWBC 4.7 8.2 4.5 - 5.2x10 LSegmenters 0.80 0.36 0.50 - 0.70Lymphocytes 0.20 0.64 0.20 - 0.40Platelet 138 190 150 - 350Urinalysis Physical Appearance Colory Yellow Yellow Transparency Slightly Hazy Clear Reaction pH 6.0 4.6 - 8.0 Specific Gravity 1.03 1.010 - 1.035 Sugar Negative Absent Protein Negative AbsentMicroscopic Pus Cell 0-3 Absent RBC 0-1 0 - 5 Epithelial Cells Occasional Protein Negative AbsentCrystal Amorphous urates Positive Amorphous Phosphate Blank Fecalysis Color Yellow Consistency Soft Typhidot IgG Positive IgM Negative
DENGUE HEMORRHAGIC FEVER
TPR SHEET
Day 1Hours Temperature Pulse
RateRespiratory
RateBlood
Pressure
8H 40.5 110 3012H 39.8 105 374H 37.5 102 358H 38.0 108 40
12H 38.8 108 304H 37.2 114 32
Day 2Hours Temperature Pulse Rate Respiratory
RateBlood
Pressure
8H 37.6 102 2412H 39.2 102 184H 39.3 122 248H 37.5 100 2712H 37.8 106 254H 38.1 108 27
Day 3Hours Temperature Pulse
RateRespiratory
RateBlood
Pressure8H 38.3 110 2812H 37.8 114 274H 38.1 116 268H 37.1 110 2712H 37.8 112 284H 38.8 116 29 90/40
DENGUE HEMORRHAGIC FEVER
Day 4Hours Temperature Pulse Rate Respiratory
Rate Blood Pressure
8H 38.2 118 4012H 38.2 118 354H 36.8 118 378H 39.4 126 4012H 38.3 114 344H 37.2 94 37
Day 5Hours Temperatur
ePulse Rate Respirator
y Rate Blood Pressure
8H 37.3 96 2312H 37.2 94 234H 36.6 82 228H 36.4 78 22
12H 36.0 70 264H 36.0 70 26
Day 6Hours Temperature Pulse Rate Blood
Pressure8H 37.3 94 28 90/50
12H 36.3 112 28 90/604H 36.4 100 288H 36.5 100 28 90/60
12H 36.0 102 264H 36.0 98 25 90/60
DENGUE HEMORRHAGIC FEVER
IV FLOW SHEET
Date
/Time
Started
Bot.
No.
Solution/
AMT/MEDS
ADDED/ RATE
IV SITE AMT
INFUSE
D
Date
/Time
Started
AMOUNT
ENDORSE
D
SIG
9/26 0745H
1 D5 0.3% NaCl 500cc x 50mggts/min
Right
Hand
500cc 2330H 30cc
9/26 2330H
2 D5IMB 500cc X 50mggts/min
Right Hand
500cc 0945H 280cc
9/26 1000H
3 D5IMB 500cc X 50mggts/min
Right Hand
500cc 9/27/06
1040H
180cc
9/28 1040H
4 D5IMB 500cc X 50mggts/min
Right Hand
500cc 9/28/06
2300H
20cc
9/28 2300H
5 D5IMB 500cc X 50mggts/min
Right Hand
500cc 9/29/06
2300H
220cc
9/29 2300H
6 D5IMB 500cc X 50mggts/min
Left Hand
500cc 9/30/06
0815H
80cc
9/30 0815H
7 D5IMB 500cc X 50mggts/min
Left Hand
500cc 10/01/06
0115H
110cc
10/01 0115H
8 D5IMB 500cc X 50mggts/min
Left Hand
500cc 10/01/06
0135H
10/01 1605H
9 D5IMB 500cc X 50mggts/min
Left Hand
500cc 10/01/06
0345H
10/01 1345H
10 D5IMB 500cc X 50mggts/min
Left Hand
500cc
DENGUE HEMORRHAGIC FEVER
IX. MEDICAL AND SURGICAL NURSING
Admission/Emergency Notes: Day 1
Assessment
Patient (+)Tonsillopharyngitis
Clear Breath Sounds
VS:
RR = 30 PR = 110
T = 40.5 BP = 90/40
Physicians Order
DIAGNOSTICS
CBC
QPC - done
Urinalysis - done
Stool Examination
THERAPEAUTICS
Admit to Pediaward
TPR every shift
DAT (Diet as Tolerated)
Monitor Vital Signs
Ampicillin 130 mg IV q8h ANST
Paracetamol 125mg/5ml 5ml q4h RTC
Paracetamol 300 mg/amp ½ ampule IV PRN
Ascorbic Acid 100mg/5ml 5ml OD
Refer to Dr. Soriano
@ 10:15 am
IVF d5 IMB 1000ml @ 50 ugtts, 24 hours
Increase ampicillin to 350 mg IV q6h ANST
@ 16:00 pm
For Bloodtyping
Physicians Order
DENGUE HEMORRHAGIC FEVER
Day 2
Continue Meds/IVF
Physicians Order
Day 3
Continue Meds/IVF
Request for Typhidot
Physicians Order
Day 4
Continue Meds/IVF
Request for CBC with QPC
VS q4h to include BP and record
Physicians Order
Day 5
IVF to follow, same
Physicians Order
Day 6
IVF to consume, D/C IV meds
MGH
Meds:
o Ascorbic acid 100ml/ 5ml 1 tsp OD
Diagnosis Dengue Hemorrhagic Fever II resolving
DENGUE HEMORRHAGIC FEVER
X. COURSE IN THE WARD
In day 1, a 3-year old male patient carried by his mother was admitted with a
chief complaint of fever. Ten hours prior to consultation, the patient had a
high grade fever and vomiting for several hours according to the mother.
The patient had a high grade fever of 40.5 0C and BP: 90/40. Diet as
tolerated was ordered. Upon assessment the patient is positive for
tonsillopharyngitis. . Anti-biotics was also part of his medication to treat his
tonsilopharyngitis. Ampicillin testing was done and had negative result. At
1000H, patient had a febrile seizure with temperature 41.80C, Paracetamol
was given. Stool examination was requested and the fecalysis result was
normal, the stool was soft, yellow colored stool. At 0100H, the patient
experienced chills with temperature of 38.80C. Paracetamol was given,
patient’s temperature went down to 370C.
In day 2, the patient is slightly febrile with temperature of 37.60C. The
mother was instructed to continue TSB and increase fluid intake.
In day 3, the patient is still febrile, Paracetamol via IV was given. Doctor
ordered for typhidot. The typhidot result were the following: IgG positive and
IgM negative. The patient is negative on typhoid fever.
In day 4, a significant drop in his temperature was noted, as low as 36.8 oC
which is a sign that the patient is entering into the toxic stage of Dengue
Fever. This state of defervescence, is a period where the number of patient’s
platelet is at its lowest. It is at this time where his attending physician
ordered another Laboratory request for CBC and PC to check if Patient X’s
platelet count is below the normal range of 150,000 to 350,000 /L, which is
referred to as thrombocytopenia. Hemoglobin, hematocrit, RBC WBC and
Platelet count are within normal limits. Segmenters are slightly decrease
with the value of 0.36 which is below the normal value of 0.50-0.70. After the
significant drop of the client’s temperature, Patient X temperature were
elevated again for eight hours, a normal phenomenon for a DHF patient
DENGUE HEMORRHAGIC FEVER
before entering into the convalescent stage. The patient had general rashes
with itchiness.
In day 5, the patient is afebrile and positive for Herman’s sign.
In day 6, the patient is afebrile and still positive for Herman’s sign.
Additional medication was ordered Ascorbic acid with dosage of 100mg/5mL
to be taken 1 tsp everyday. Diagnosis of Dengue Hemorrhagic Fever II was
resolved. The patient was discharged.
DENGUE HEMORRHAGIC FEVER
XI. Drug Study
BRAND NAME/GENERIC
CLASSIFICATION ACTION ROUTE&DOSAGE CONTRAINDICATIONS NURSING INTERVENTION
PARACETAMOLAcetaminophen
Antipyretic Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulating center.
Paracetamol 125mg/5ml PO – 5ml q4 RTCParacetamol 300mg/ampIV – ½ ampule IV PRN
- Contraindicated in patients hypersensitive to drug.· Use cautiously in patients with long term alcohol use because therapeutic doses cause hepatotoxicity in these patients.· Hematologic: hemolytic anemia, neutropenia, leukopenia, pancytopenia.· Hepatic: Jaundice· Metabolic: hypoglycemia· Skin: rash, urticaria.
- Use liquid form for children and patients who have difficulty swallowing.· In children, don’t exceed five doses in 24 hours.· Advise patient that drug is only for short term use and to consult the physician if giving to children for longer than 5 days or adults for longer than 10 days.· Advise patient or caregiver that many over the counter products contain acetaminophen; be aware of this when calculating total daily dose.· Warn patient that high doses or unsupervised long term use can cause liver damage.
DENGUE HEMORRHAGIC FEVER
BRAND NAME/GENERIC
CLASSIFICATION ACTION ROUTE&DOSAGE CONTRAINDICATIONS NURSING INTERVENTION
AMPICILINAmpicillin
Anti-infective Antibiotic(Penicillin Family)
Inhibits cell wall synthesis during microorganism multiplication
Ampicillin: 130 mg IV q8h ANST
Children age 1 and older weighing less than 40kg (88lb): 300mg/kg daily IV in individual doses every 6 hours. Don’t exceed 4 g daily .
- Contraindicated in patients hypersensitive to drug or other penicillins
.
- Use cautiously in patients with other drug allergies because of possible cross sensitivity- Before giving drug, ask patient about allergic reactions to penicillin. However a negative history of penicillin allergy is no guarantee against a future allergic reaction- Obtain specimen for culture and sensitivity test before giving first dose. Therapy may begin pending results.-decrease dosage in patients with impaired renal function- Don’t use IM route in children-Monitor liver function test results during therapy- if large doses are given superinfection may occur
DENGUE HEMORRHAGIC FEVER
BRAND NAME/GENERIC
CLASSIFICATION ACTION ROUTE&DOSAGE CONTRAINDICATIONS NURSING INTERVENTION
Ascorbic Acid Vitamins and Minerals
Stimulates collagen formation and tissue repair, involved in oxidation-reduction reactions
For extensive burns, delayed fracture or wound healing, severe febrile or chronic disease states
Oral liquid 100mg/5ml - 5ml OD
Contraindicated in patients with an allergy to tartrazine or sulfites. Large doses are contraindicated during pregnancy
Protect solution from light (IV) and refrigerate ampules
For patient receiving Vit. C, IM route may promote better utilization
Inform patient that Vit C is readily absorbed from citrus fruits, tomatoes, potatoes and leafy vegetables.
DENGUE HEMORRHAGIC FEVER
Assessment Nursing Diagnosis
Inference Goal Intervention Rationale Evaluation
SUBJECTIVE:“Kahapon pa siya inaapoy ng lagnat”, as verbalized by the patient’s mother.OBJECTIVE: Increase in body
temperature above normal range: 40.5 C
Profused Sweating
Dry lips and mucous membrane
Flushed skin Warm to touch
Hyperthermia related to direct effect of circulating endotoxins on the hypothalamus, altering temperature regulation.
Dengue Fever
Elevated WBC’s
Release of endotoxins, that cause disruption of hypothalamic set point
Increase in body temperature
After 8 hours of nursing intervention, the patient will demonstrate a temperature within the normal range, free of chills and associated complications.
Monitor patient temperature (degree and pattern) and note shaking chills or profused diaphoresis.
Monitor environmental temperature; limit or add bed linens as indicated.
Provide tepid sponge baths; avoid use of alcohol.
Administer antipyretics like acetylsalicylic acid (aspirin) and acetaminophen (Tylenol).
Provide cooling blanket.
Temperature of 38.9 - 41.1 C suggests acute infectious diseases process. Fever pattern may aid in diagnosis.
Room temperature or number of blankets should be alterd to maintain near normal temperature.
May help reduce fever. Use of alcohol may cause chills, actually elevating temperature.
Used to reduce fever by its central action on the hypothalamus.
Used to reduce fever usually greater than 40 C when seizures can occur.
Goal is met,after 8 hours of nursing intervention, the patient achieved a temperature within the normal range as evidenced by a decreased in body temperature from 40.5 C to 37 C. Patient was also free of chills and associated complications.
Assessment Nursing Diagnosis
Inference Goal Intervention Rationale Evaluation
Dengue Hemorrhagic Fever
Subjective: “Ayaw kumain ng anak
ko ”, as verbalized by the patient’s mother.
Objective: Decreased tolerance
for activity Weakness Loss of muscle tone Weight upon
admission in kilogram: 13
Imbalanced Nutrition: less than body requirement related to loss of appetite secondary to dengue virus
Dengue Fever
Joint pain
Nausea, vomiting
Anorexia
Decreased appetite
After 3 days of nursing intervention, patient will demonstrate stable weight and will be free of signs of malnutrition. Patient or mother will demonstrate behaviors or lifestyle changes to maintain appropriate weight.
Independent:
Assess causative/ contributing factor:
Assess client's weight, age, strength, activity/rest level, and so forth Assess nutritional history, including food preferences
Observe and record patient’s food intake
Encourage client to choose food that are appealing to increase appetite
Avoid foods that causes intolerance, increase gastric motility that results in epigastric pain
Dependent:Establish a nutritional plan that meets individual needs:
Avoid foods that cause intolerances/
Provides comparative baseline
Identify deficiencies, suggests possible interventions
To monitor caloric intake or insufficient quality of food consumption
Toddlers eat a lot of food that are appealing to their taste
Foods such as gas-forming, spicy, too hot, too cold, caffeinated beverages can result to epigastric pain that will decrease appetite leading to weight loss
To enhance intake
To implement
Goal is met, after 3 days of nursing intervention, patient demonstrated stable weight and is free of signs of malnutrition. Patient’s mother also verbalized and demonstrated behaviors and lifestyle changes to maintain patient’s appropriate weight.
Dengue Hemorrhagic Fever
increase gastric motility
Consult dietitian/nutritional team as indicated
Provide nutritious food and diet modification as indicated.
Small frequent feeding with aspiration precaution
Promote pleasant, relaxing environment
Promote adequate/timely fluid intake
Weigh as often as possible and PRN
Note occurrence and report of constant sore throat.
Family support: Significant others should provide positive regard, love, and acknowledgement in guiding client with eating problem.
interdisciplinary team management
To prevent dehydration
To monitor effectiveness of efforts
Presence of inflamed throat may affect ability to eat/lose of appetite
Assessment Nursing Diagnosis
Inference Goal Intervention Rationale Evaluation
Dengue Hemorrhagic Fever
Subjective:“Nanghihina at nanglalambot sya. Ni hindi nga nya kaya umupo para uminom ng gamot”, asverbalized by the patent’smother.
Objective: Decreased
tolerance for activity
Greater need for sleep and rest
Weakness and fatigue
Activity intolerance related to generalized weakness and reduced energy stores
Fever
Nausea and vomiting
Anorexia
Decreased appetite
Reduced energy stores
Muscle weakness and fatigue
After 8 hours of nursing intervention, the mother will report a measurable increase in activity tolerance
Assess patient’s ability to perform normal tasks noting complaints of weakness and fatigue
Provide quiet atmosphere, uninterrupted rest periods and maintain bed rest.
Implement energy-saving techniques like sitting, rather than standing, when administering oral medications or when providing tepid sponge baths.
Influences choice of intervention and needed assistance
Enhances rest to lower body’s oxygen requirements and reduces strain on the body
Maximizes available energy for other tasks.
Goal is met after 8 hours of nursing intervention, patient’s mother has reported a measurable increase in patient’s activity tolerance as evidenced by lesser complaints of fatigue and weakness and by increased tolerance in activities like sitting up to drink medicines
Assessment Nursing Diagnosis
Inference Goal Intervention Rationale Evaluation
Dengue Hemorrhagic Fever
Objective:- Weakness andirritability.- Restlessness.
Laboratory Values:Platelet count: 130/ L
Hct : 0.41%Hgb: 13.6%
Risk for injury/bleedingrelated toaltered clottingfactor secondary to the coagulopathy effect of dengue virus
Dengue virus
Immune response involving production of cytokines and chemokines
activation of T-lymphocytes
vasculopathy, increase capillary fragility
disturbance of hemostatic system
thrombocytopenia and platelet dysfunction
prolongation of PT and PTT time
Severe bleeding
After 8 hours of nursing intervention, the motherof the client will learn through health teaching and demonstration the skills and practices in preventing injury to the patient that will cause him to bleed and to identify the signs of ongoing internal bleeding
Independent:- Assess for signs and symptoms of G.I bleeding. Check forsecretions. Observe color and consistencyof stools or vomitus.
- Observe for presence of petechiae, ecchymosis, bleeding from one more sites.
- Monitor pulse,Blood pressure.
- Note changes in mentation andlevel of consciousness.
- Avoid rectal temperature, be gentle with GI tube insertions.
- Encourage use of soft toothbrush, avoiding straining for stool, andforceful nose blowing.
- Use small needles forinjections. Apply pressure to venipuncture sites for longer than usual.
- Recommend avoidance of aspirin containing products.
Collaborative:
- The G.I tract (esophagus andrectum) is the most usual source of bleeding of its mucosal fragility.
- Sub-acute disseminatedIntravascular coagulation(DIC) may developsecondary to altered clotting factors.
- An increase inpulse with decreasedBlood pressure can indicate loss ofCirculating blood volume.
- Changes mayIndicate cerebralPerfusion secondary to,Hypoxemia
- Rectal andEsophageal vessels are most vulnerableto rupture.
- In the presenceof clotting factordisturbances,minimal trauma can cause mucosal bleeding.
- Minimizes damage to tissues, reducing risk for bleeding andhematoma.
- Prolongs coagulation, potentiating risk of hemorrhage.
Goal is met after 8 hours of nursing intervention, the motherof the client learned through health teaching and demonstration the skills and practices in preventing injury to the patient that will cause him to bleed as evidenced by providing soft toothbrush to the client and mother also identified the signs of ongoing internal bleeding as evidenced by frequent observation of the patients stool color
Dengue Hemorrhagic Fever
Dengue Hemorrhagic Fever
Assessment Nursing Diagnosis
Inference Goal Intervention Rationale Evaluation
OBJECTIVE:
Rashes on chest area Mild scratching of patient is observed
Risk for impaired skin integrity related to the dengue virus as evidenced by mild scratching
Dengue virus infection
Immunoglobulin antibodies
attached to the surface of mast cells bind with an
antigen
Immune response system is activated
Histamine and chemoctactic substance are
released
Histamine causes permeability of blood vessels and peripheral
vasodilation
Resulting to non-specific febrile
illness with rash
After 8 hrs nursing intervention the patient will maintain optimal skin integrity as evidence by absences of skin breakdown
Independent:
Assess for rashes which may be present on other areas of body
Keep fingernails short
Apply cold compress or quick cold bath if not contraindicated
Maintain skin hygiene using mild soap and lukewarm water. Pat dry skin gently and thoroughly
Encourage adequate nutrition and hydration
Provide or advice
Hermans rash/sign usually appears on the upper and lower extremities about 1cm or less in size. Although typically located in extremities, unusual manifestation of rash may be generalized classic rash. Itchiness may be present at times
To prevent skin excoriation and secondary infection caused by scratching
To ease and give comfort to skin itchiness. Cold compress is vasoconstrictor which can reduce swelling
Skin hygiene needed to prevent secondary infection and avoid rubbing skin to prevent skin breakdown. Avoid harsh soaps that can dry and cause skin breakdown
To promote healthy skin
To prevent sweating and keep the skin dry.
Goal is met after 8 hours of nursing intervention, the clients skin integrity is not impairedas evidenced by the client’s intact skin that is free from breakdown and cuts
Dengue Hemorrhagic Fever
Assessment Nursing Diagnosis
Inference Goal Intervention Rationale Evaluation
significant other to use light clothing material that is comfortable to the client
Use of baby powder after bathing or cleaning as indicated
Remove wet and wrinkled bed sheets promptly. Keep bed clothes dry, use non irritating materials and keep bed free of wrinkles, crumbs etc
Collaborative: Administer anti-itchiness as prescribe
Sweat can potentiate skin irritation and scratching
Moisture potentiates skin breakdown. Dry, crisp linen provides comfort to the client
To provide maximum relief from itchiness
To relieve client from itchiness
Dengue Hemorrhagic Fever
Assessment Nursing Diagnosis Inference Goal Intervention Rationale Evaluation
Objective:
Length of Stay: 5 days (ongoing)
Admitted at Pediatric Ward - sharing with other sick clients in a 15 bed capacity room
Risk for nosocomial infection related to prolonged hospital stay
Dengue virus
Prolonged hospitalization
(ongoing 5 days)
Exposure to pathogens
Risk for nosocomial infection
After an 8 hr of nursing intervention, the client’s significant others will verbalize understanding of desired preventive/precautionary skills in maintaining an aseptic environment to the client
-Observe for localized signs of infection at insertions sites of invasive lines, sutures, surgical incisions/wound
-Assess and document skin conditions around insertion of parenteral line
-Note signs and symptoms of sepsis, fever, chills, diaphoresis, altered level of conciousness, positive blood cultures
-Stress proper handwashing techniques by all caregivers
-Monitoring of visitor to prevent exposure of client
-Maintain sterile technique for invasive procedure such as IV line
-Review individual nutritional needs, and adequate rest
-Emphasize the necessity of taking antibiotics as directed
-Insertion sites of invasive lines, sutures, and surgical incisions are the most common site of infection
-Redness, swelling and pain are the signs of infection
-Early detection of infection will result in early diagnosis and treatment
-Proper handwashing lessen the transmission of pathogens
-Visitors can transmit pathogens to the client
-Infection can occur if the sterility of the procedure during IV insertion is compromised
-Adequate rest and nutrition helps maintain stability of the body therefore immune system is not compromised
-Completing the medicated antibiotics will treat the infection
Goal is met, after an 8 hr of nursing intervention, As evidenced by the client identifying/ practicing the appropriate behaviors and skills in maintaining an aseptic environment favorable to the client as evidenced by performing frequent handwashing before and after eating and attending to his child
Dengue Hemorrhagic Fever
XIII. HEALTH TEACHING
Medication
Intake of appropriate vitamin supplement to increase protection
mechanism of the immune system
Management
Management of such condition would be through hydration and doing
control measures to eliminate vector by promoting cleanliness in the
environment through proper disposal of rubber tires, changing water of
lower vases once a week, destruction of breeding places of mosquito
and residual spraying with insecticides.
Outpatient/Follow-up
Any odd signs such as fever, petechiae, recurrence of fever, etc. must
be immediately reported to the physician
There is no vaccine available to prevent dengue fever. Use personal
protection such as full-coverage clothing, netting, mosquito repellent
containing diethylmetatoluamide (DEET), and if possible, travel during
periods of minimal mosquito activity. Mosquito abatement programs
can also reduce the risk of infection.
DENGUE HEMORRHAGIC FEVER
References:
Suzanne C. Smeltzer Brenda G. Bare, Brunner & Suddarths’s Textbook
of Medical Surgical Nursing, 10th Edition, 2004
Frances Prescilla L. Cuevas, RN MAN, Public Health Nursing in the
Philippines, 10th Edition 2007
Catherine Paradiso, Lippincot’s Review Series – Pharmacology, 1998
Websites:
http://www.merck.com/mmpe/sec14/ch191/ch191b.html#sec14-ch191-
ch191b-2577
http://doh.gov.ph/
http://www.webmd.com/video/travel-dengue-fever
DENGUE HEMORRHAGIC FEVER