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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, Man Clinical Instructor Submitted By AÑABIEZA, Babyrlene P. Date of Rotation
July 19-21, 26-28, 2010
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,
gingival bleeding. early detection or diagnosis and medications which are essential for total interference of prevention. Rapid deterioration Deterioration occurs after 2–5 days of the typical symptoms of dengue fever 2. Irritability Associated with rapid deterioration 3. 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. vomiting. Restlessness Associated with rapid deterioration 4. or diarrhea. hematemesis or upper gastrointestinal bleeding. Causative agent It is caused by four antigenically related but distinct serotypes of the dengue virus DEN1. cold clammy skin and weak pulse) * Grade IV: Grade III + Shock. Mode of transmission A strain of Arbovirus caused Dengue Hemorrhagic Fever and transmitted by the Aedes aegypti mosquito. decreased platelet count (thrombocytopenia). 3. Blood test for antibodies. Weak and rapid pulse Related to hemorrhage 6. nausea.g: vomiting of blood). There are also rashes characterized by bright red petechaie commonly seen on the lowers limbs and on the chest. 2. Characteristics of an Aedes aegypti mosquito: 1. Diagnostic Tests 1. Complications list for Dengue fever: . Daybiting 2. e. Ask the client about a history of travel to tropical or subtropical areas. DEN-3 and DEN-4. DEN-2. Proper attention of health care provider should be given including good assessment. and increased hematocrit. * Grade III: Grade II + Circulatory Collapse (hypotension. Low blood pressure Related to hemorrhage 5. In urban area Incubation Period There is an incubation period of 3-14 days (usually about 4-7). Complete blood count to detect elevated white blood cell count. Signs and Symptoms 1.muscle and joint pains which will give name to Breakbone Fever or Bonecrusher. There may also be gastritis associated to abdominal pain. Low-flying 4. and melena or dark stool.
* Replacement of plasma or plasma expanders. Aspirin and nonsteroidal anti-inflammatory drugs should be avoided as these drugs may worsen the bleeding tendency associated with some of these infections. (DHF) Oxygen and sedatives may be administered.Shock.Tiredness . Prevention of Dengue hemorrhagic fever: Methods of prevention of Dengue hemorrhagic fever mentioned in various sources includes those listed below. there is no specific medicine or antibiotic to treat it. The presence of melena or blood in the stool may indicate internal gastrointestinal bleeding requiring platelet and/or red blood cell transfusion.The list of complications that have been mentioned in various sources for Dengue fever includes: • Fatigue . For typical dengue. Acetaminophen (Tylenol) and codeine may be given for severe headache and for the joint and muscle pain (myalgia). Nursing Management Dengue is a self-limited illness but recovery might take a few weeks. Collaborative: A platelet transfusion is indicated in rare cases if the platelet level drops significantly (below 20. Treatment is purely concerned with relief of the symptoms (symptomatic). * Analgesics (not aspirin) for fever and muscles aches. Increased oral fluid intake is recommended to prevent dehydration. Dependent: Because dengue is caused by a virus. Rest and fluid intake for adequate hydration is important.Dengue hemorrhagic fever . Very low blood pressure .this can cause several serious complications(Bleeding . Treatment is solely supportive and includes: * Fluids. the treatment is purely concerned with relief of the symptoms (symptomatic).000) or if there are significant bleeding. Acetaminophen (Tylenol) and codeine may be given for severe headache and for the joint and muscle pain (myalgia). This prevention information is gathered from various . Aspirin and nonsteroidal anti-inflammatory drugs should only be taken under a doctor's supervision because of the possibility of worsening hemorrhagic complications.Death) Medical Management Because dengue fever is caused by a virus. Management Do not give Aspirin because it contains at antiplatelet property which prmotes bleeding. there is no specific medicine or antibiotic to treat it. Independent: Close monitoring of vital signs in critical period (between days 2 to day 7 of fever) is critical.
None of these methods guarantee prevention of Dengue hemorrhagic fever. headache. a.not yet available but being researched. and may be inaccurate or incomplete. • • • • • • • • • See prevention of dengue Avoid mosquito bites Mosquito repellant Protective clothing Window screens Remove water-filled mosquito breeding areas Dengue vaccine . 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.2 PRESENT ILLNESS • Four days prior to admission.sources.1 CHIEF COMPLAIN Fever Patients Hx • The patient complains of abdominal pain. the patient had an intermittent fever associated with abdominal pain. and general flushing of the . headache. 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. fever and general flushing of skin with on and off vomiting.
a. she goes directly at home to relax. HISTORY OF ILLNESS . she eats vegetables and fish instead she prefers eating hotdogs.6 ENVIRONMENTAL HISTORY • According to the patient the environment that the family has an open drainage. Before that diagnosis. Hence. SJ. a. After working hours.skin with on and off vomiting. and Mrs. wherein big rats and cockroaches can be seen.4 FAMILY HISTORY • According to her grandmother the only disease that the family has genetically is Diabetes Mellitus and no other diseases noted. According to Miss X.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. Furthermore she has no vices except for computer games. The house is cleaned by her mother and grandmother. CJS is currently working at Toshiba as an employee at Sta. Rosa Citys. 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. she was already experiencing fever and her mom gives her a Paracetamol for remedy. a. It was described by the patient that there are parts of their house that is deprived from light. Her father works as a seaman while his mother is a housewife. a.5 SOCIAL HISTORY • • Miss X is the daughter of Mr. her grandmother and her mother were the ones responsible in all the household chores. C. her grandmother is also living with them.
her parent decided to bring her to the hospital.• During the mid of. As a remedy her mom gave her Paracetamol to lower her body temperature. was diagnosed of having Dengue Fever Syndrome (DFS).At the clinical check-up. Except from fever she’s also experiencing abdominal pain. headache and general flushing of the skin with on and off vomiting. she was diagnosed with Dengue Fever Syndrome (DFS) and was admitted under the service of Dr. The case of Miss X can be correlated with the theory of Florence Nightingale . Upon the physical assessment and after several diagnostic procedures that the patient had undergone. Application Theory: The case of CJS can be correlated with the theory of Nightingale wherein. started experiencing fever that persist only at night. Olivares. . As the above signs and symptoms persists. Having a clean. THEORETICAL FRAMEWORK Miss X. . well ventilated and quite environment is important in. the environment of the patient is a factor leading to recovery. With a nurturing environment. Olivares. the body could repair itself. the physician was able to identify some clinical signs of it and was referred to Dr. Miss X.
scars or inflammation Smooth Moist The skin springs back to its previous state after being pinched Actual Findings General flushing No lesions.PHYSICAL ASSESSMENT (Normal Findings Actual Findings Rationale) Area Assessed SKIN Color and pigmentation Lesions Texture Moisture Temperature Mobility and turgor NAILS Nail bed color Shape Lesions Thickness capillary refill Method Used Inspection Inspection Palpation Palpation Palpation Palpation Normal Findings Light to deep brown No lesions. but presence of scars Smooth Moist The skin springs back to its previous state after being pinched Pale Convex No inflammation of the skin around the nail Firm Normal capillary refill Rationale Decrease WBC in the body Normal Normal Normal Normal Normal Inspection Inspection Inspection Palpation Palpation Pink Convex No inflammation of the skin around the nail Firm Decrease RBC in the body Normal Normal Normal Normal (less than 3secs) .
curved outward Pink conjunctiva Evenly distributed Evenly distributed Normal Normal Normal .HEAD Size Symmetry Inspection Inspection Proportion to the body and the skull is rounded and smooth Symmetrical Black Curly hair. lumps or masses No inflammation. lumps or masses Normal Normal Normal Inspection Inspection Inspection Light to deep brown Smooth Symmetric facial movement Pinkish Symmetric facial Symmetric facial movement Due to fever Normal Normal EYES External structure Eyebrows Eyelashes Eyelids Inspection Inspection Inspection Inspection Evenly distributed Evenly distributed. straight No nits/lice present HAIR Color Texture Other findings SCALP Distribution of hair Lesions Other findings FACE Skin color Texture Facial movement Inspection Inspection Inspection Proportion to the body and the skull is rounded and smooth Symmetrical No nits/lice present Normal Normal Normal Normal Normal Inspection Inspection Inspection Evenly distributed No inflammation. Evenly distributed.
EARS Color Symmetry Shape and size Inspection Inspection Inspection Same as facial color Symmetrical at the level of the eyes corner Symmetric to head No discharges and inflammation Same as facial color Same with facial color Symmetric No discharges Symmetric to head No discharges and inflammation Normal Normal Normal Normal NOSE Color Shape Discharges MOUTH Lips Symmetry Moisture TONGUE Position Color Texture Mobility Lesions Inspection Inspection Inspection Same with facial color Symmetric No discharges Normal Normal Normal Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Symmetric Pink Moist Positioned at the center can move freely Dull red Smooth Can move freely No lesions or inflammation Symmetric Pink Dry Central position Dull red Smooth Can move freely No lesions or inflammation Normal Normal D/t poor nutrition Normal Normal Normal Normal Normal .
deformities or inflammation Normal Normal Normal Normal Normal Due to disease Normal . deformities or inflammation Normal Equal size Symmetrical Evenly distributed Light to deep brown No lesions.NECK Position Symmetry Range of movements Inspection Inspection Inspection Palpation Head centered Symmetrical Smooth movements without discomfort Symmetric and at midline position Head centered Symmetrical Smooth movements without discomfort Symmetric and at midline position Normal Normal Normal Normal UPPER AND LOWER EXTREMITIES Size Symmetry Distribution of hair Skin color Lesions Temperature Inspection Inspection Inspection Inspection Inspection Inspection Equal size Symmetrical Evenly distributed Light to deep brown No lesions.
longanisa. and others.GORDON’S 11 FUNCTIONAL HEALTH PATTERN FUNCTION Nutrition BEFORE HOSPITALIZATION • Eats 3x a day • She loves to eat bread & processed foods such as hotdog. tocino. • She doesn’t eat vegetables and fish • Seldom drinks water 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 • Has a regular sleeping pattern • Normal sleep is 6-8 hrs. per day but she naps for 1-2 hrs in the afternoon • Has a normal cognitive perception • Can comprehend well • She responds appropriately to DURING HOSPITALIZATION • Mostly eat bread INTERPRETATION • The Doctor ordered DAT diet to the patient except dark colored food Elimination This time she frequently drinks water • She can still urinate & defecate by herself even without an assistance • • • To replace fluid loss Her condition doesn’t affected her elimination pattern Sleeping • Disturbed sleeping pattern • Due to adherence to time of medication & vital signs monitoring CognitivePerceptual Pattern • She is responsive • & can communicate well Portraying cooperativeness .
• Same • Due to her age.• Perceived herself Health her health in the Self concept as a good friend. Coping Stress & • Tolerance Pattern Activity-Exercise Pattern • • • She interacts with his grandmother & other people around her Cooperates well to the doctor & nurses. She only focuses on simple things. Her daily activities were limited in waking up in the morning to attend his class & after that going to computer shop. Her daily routine on playing computer. she still has a playful mind & she doesn’t mind the stressors in life. as a patient is not she is not aware of fully met performing her real role in this field. Role Relationship Pattern SexualityReproductive Pattern • He was able to do his responsibilities as a son & brother She thinks of having a boyfriend & getting married.verbal & physical stimuli Health Perception • She perceived Self-–Perception. it is still not her priority in life • Same • At her age. Management state of good brother & Pattern condition DAughter. • Value-Belief Pattern • • Due to their culture preferences & parent’s influence Anatomy And Physilology The Circulatory System . She doesn’t fully identifies her stressors. She is a Catholic • • She thinks that • Due to her illness • This is not he • Due to her ability to she times perceives herself establish good rapport healthy as an to other people approachable person • This time his role • Due to his condition.
is the capillaries. .The 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.
releasing additional blood into the circulatory system as needed. old red blood cells. The spleen serves as a reservoir for blood.The Lymphatic System An often overlooked part of the circulatory system is the lymphatic system. to prevent backflow. impurities such as bacteria. like the veins. some of the fluid diffuses into the surrounding tissues. Babyrlene P. both of which transport the lymph back into veins of the shoulder areas where is mixes with blood and is returned to the heart. lymph flows into the thoracic duct. Cells of the lymph nodes phagocytize. a large vessel that runs parallel to the spinal column. One function of the lymphatic system is to collect and recycle this fluid (called lymph). It is also involved with destruction of old cells and other substances by phagocytosis. Lymph passes from capillaries to lymph vessels and flows through lymph nodes that are located along the course of these vessels. or into the right lymphatic duct. All lymph vessels contain one-way valves. MAN BSN 4A Clinical Instructor Miss . We will cover the lymphatic system in detail in the lesson on the immune system. or ingest. As blood passes through the capillaries. Añabieza Edith Vizcarra RN. and is a very important part of the immune system. The tissues of the lymphatic system include the spleen. and toxic and cellular waste. The lymphatic system is also responsible for collecting nutrients that the digestive system has extracted from our foods. Finally.
Allinson AC: Dengue virus and mononuclear phagocytes. Reference: Halstead SB. 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. 2. Since ultrastructural analysis of this interaction has not been reported. . O'Rourke EJ. Identity of blood and tissue leukocytes supporting in vitro infection.“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. dengue type 2 (DEN2) virus-infected human monocyte cultures were studied at 1. Ultrastructural features associated to DEN2 virus replication were not observed. blebbing and budding phenomena and phagocytosis of apoptotic cells by neighboring monocytes. Viruses were engulfed by phagocytosis and macropicnocytosis leading to huge vacuoles and phagosomes inside the monocytes. cellular shrinkage. Interaction of monocytes with DEN2 virus induced apoptosis. Results Typical dengue particles and fuzzy coated viral particles were 35 to 42 nm and 74 to 85 nm respectively. 4 and 6 hours after infection. This finding was confirmed by TUNEL. II. characterized by nuclear condensation and fragmentation.
back pain. vomiting. nephrotoxicity . Rash. blood Patients dyscrasias . myalgias. toothachge. anemia. Impaired liver or kidney function . dysmenorrheal. etc. Relief of headache.neuralg ias. nausea. hypersensitivity reactions Nursing consideration Patients with alcoholic liver disease. analgesic nephropathy . Analgesics and anti pyretic for patients hypersensitive to aspirin Adverse Effect Contraindication Nonopoiod Produce analgesics and analgesia anti pyretics by blocking pain impulses by inhibitinfg synthesis of prostaglandi n in the CNS or of other substances that sensitize pain receptors to stimulation.Brand name/ Generic name Acetaminophen (Paracetamol) Classification Action Indication Symptomatic relief of pain and fever. Hypersensitivity.
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. urinary tract > Drugs that inhibit peristalsis. & family’s knowledge of drug therapy . growing adolescents.Brand name/ Generic name Classification Action . Pregnancy and lactation > Drugs that inhibit peristalsis. eyes. middle ear.paranasal sinuses. Inhibits Indication Adverse Effect Contraindication Nursing consideration Generic Name: Ciprofloxacin Brand Name: Pharex Ciprofloxacin Classificatio n: Antiinfectives bacterial DNA gyrase thus preventing replication in susceptible bacteria > Infections of the resp. kidneys. Infants and children. growing adolescents. Infants and children. tract.
Brand name/ Generic name Classification Action . Indication Adverse Effect Contraindication Nursing consideration Generic Name: Brand Name: Classificatio n .
ASSESSMENT Subjective: “Masakit ang tiyan ko” as verbalized by the patient. 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 .v. grimace & irritability SCIENTIFIC EXPLAINATION . Objective: >C pain scale of 7/10 >grimace noted >irritable >weakness noted Characteristic: Stabbing.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. shooting pain Onset: “pasumpong sumpong po eh” as verbalized by patient Location: No exact Location” sa buong tiyan poh as verbalization Duration: 2-3 minutes Exacerbations: Gets worst when pressure is applied in the NURSING DIAGNOSIS Acute pain related to inflammatory response as evidenced by verbalization of patient “ masakit po tiyan ko” pain scale of 7/10. >Place patient in a comfortable position >Encourage to have adequate bed rest >Provided therapeutic touch Dependent: >Administered Ranitidine as ordered RATIONALE > 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 EVALUATIO N Goal Partially met. swelling and pain PLANNING With in 30 minutes and for the whole period of duty the patient will be free from pain from 7/10 to 1/10 INTERVENTION Independent: >monitor v/s >Instructed to deep breathing excersise >Encourage to have Diversional activities like watching t.
38. After 45 minutes of nursing care.stomach Radiation: Radiates in the whole abdomen Relief: “ kapag iniipit ko tiyan ko nwawala minsan sakit” >skinwarm to touch >flushed skin >temp. loosen clothing. 38 >c dry lips Elevated body temperature related to presence of infection or inflammatory response as evidenced by temp. the patient temperature decrease from 38C to 36.8 as evidenced by normal temp and absence of flushing and cool skin . 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 >To promote Surface cooling and allow heat to release >To replace fluid >Encourage to increase oral fluid loss due to body heat intake >Promote Surface >To release heat through evaporation cooling. and cool and conduction environment >To reduce >Encouraged to metabolic demand have adequate and regain energy bed rest Dependent: >To decrease >Administer temperature and Paracetamol as support circulating ordered volume and tissue perfusion Goal met.
90 0.60 -0. Normal Values 5 – 10 x 10 ^/L Segmenters 0.08 116 0.Environment WBC 12.8 Non.54 Platelets Count 110 150 – 450 x 10 ^/ L Due to presence of bleeding ↓ 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 .70 Increase Segmenters indicates the presence of an acute bacterial infection or some inflammation going on inside the body Decrease Lymphocytes indicates can be sign of infection.predisposing Factor: .Female Increase WBC indicates Leukocytosis can be a sign of infection.Age: Interpretation .40 – 0.20 – 0.PATHOPHYSIOLOGY Predisposing Factor: -Immuno Exam compromised Result .35 0.40 140 -180 0. Normal Normal Lymphocytes Hgb Hct 0.
educate the family/patient on how to eliminate those vectors. Health Teaching: > D. Kinins) ↓ Vascular response ↓ Redness & Heat ↓ Headache. > Give oresol to replace fluid in the body. D. Vomiting Epistaxis.discuss the possible source of infection of the disease.S a thirteen year-old male patient. who was diagnosed with Dengue Hemorrhagic Fever. Patient's Name: > C. Abdominal pain Circulatory Collapse Shock ↓ DEATH Discharge Planning A. meat and fruits. E. B. > E. . C. Medications: > Give acetaminophen in case the temperatures increases.↓ Stimulates intense inflammatory response ▼ Release of exogenous pyrogens ↓ ↑ WBC (Neutrophils & Macrophages) ↓ Release of endogenous pyrogens ↓ Reset of hypothalamic thermostat ↓ Fever ▼ ▼ Muscle contract Blood vessels To produce construct to Additional heat prevent loss of body heat ↓ ↓ SHIVERING CHILLS ▼ body releases anti- inflammatory mediators (Histatin. Treatment: > Increased oral fluid intake. Diet: > Encourage nutritious foods like vegetables.J.
> N.Never stocked water in a container without cover. > E. > G.Encourage the family of the patient to clean the surroundings to destroy the breeding places of mosquito.Gallon. . > U.Use insecticides at home to kill or reduce mosquito. container and tires must have proper way of disposal.
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