Saint Michaels College of Laguna School of Nursing & midwifery

Old National Road, Platero Bian 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 AABIEZA, Babyrlene P. Date of Rotation

July 19-21, 26-28, 2010

INTRODUCTION

GOAL

To be knowledgeable about the nature of Dengue Fever Syndrome, management and treatment to be able to render effective nursing care to the client.

To be knowledgeable on how to prevent the disease To know the treatment and how to apply it
To know the diagnostic exam

We live in our world today where everything seems to be in a fast face.

As it is, we cannot deny that things change over or in a certain period of time. New technologies were being invented, clothes for fashion, jewelries, luxuries mode of entertainment, etc. Its just like having a new mode of socialization, cultures, beliefs, perceptions, adaptation to life and environment. With all of these, one aspect of human being which are greatly affected and the one which we have to be most concern of would be in the side of our heath and well being.

In the Philippines there are many diseases illness arising because of environmental changes that may be caused by human activities and geographical conditions. It is considered as one of the tropical country and so disease can spread through out the country.

One example of these is disease is what we called Dengue Fever and dengue Hemorrhagic Fever (DHF). It is considered as one of the acute febrile diseases caused by one of the four closely related virus serotype of the genus flavivirus. It can be transmitted by Aedes Aegypti mosquito to humans usually attacking during the day. One will experience onset of fever, severe headaches,

muscle and joint pains which will give name to Breakbone Fever or Bonecrusher. There are also rashes characterized by bright red petechaie commonly seen on the lowers limbs and on the chest. There may also be gastritis associated to abdominal pain, nausea, vomiting, or diarrhea. Proper attention of health care provider should be given including good assessment, early detection or diagnosis and medications which are essential for total interference of prevention.

Causative agent It is caused by four antigenically related but distinct serotypes of the dengue virus DEN1, DEN-2, DEN-3 and DEN-4. Mode of transmission A strain of Arbovirus caused Dengue Hemorrhagic Fever and transmitted by the Aedes aegypti mosquito. Characteristics of an Aedes aegypti mosquito: 1. Daybiting 2. Low-flying 4. In urban area Incubation Period There is an incubation period of 3-14 days (usually about 4-7). Signs and Symptoms 1. Rapid deterioration Deterioration occurs after 25 days of the typical symptoms of dengue fever 2. Irritability Associated with rapid deterioration 3. Restlessness Associated with rapid deterioration 4. Low blood pressure Related to hemorrhage 5. Weak and rapid pulse Related to hemorrhage 6. Petechial rash Related to hemorrhage Stages of Dengue Hemorrhagic Fever * Grade I: fever + Herman's sign (flushes and redness of skin with lighter color at the center of the rash) * Grade II: Grade I symptoms + bleeding (epistaxis or nosebleeding, gingival bleeding, hematemesis or upper gastrointestinal bleeding; e.g: vomiting of blood), and melena or dark stool. * Grade III: Grade II + Circulatory Collapse (hypotension, cold clammy skin and weak pulse) * Grade IV: Grade III + Shock. Diagnostic Tests 1. Complete blood count to detect elevated white blood cell count, decreased platelet count (thrombocytopenia), and increased hematocrit. 2. Blood test for antibodies. 3. Ask the client about a history of travel to tropical or subtropical areas.

Complications list for Dengue fever:

The list of complications that have been mentioned in various sources for Dengue fever includes:

Fatigue ,Tiredness ,Dengue hemorrhagic fever - this can cause several serious complications(Bleeding ,Shock, Very low blood pressure ,Death)

Medical Management
Because dengue fever is caused by a virus, there is no specific medicine or antibiotic to treat it. For typical dengue, the treatment is purely concerned with relief of the symptoms (symptomatic). Rest and fluid intake for adequate hydration is important. Aspirin and nonsteroidal anti-inflammatory drugs should only be taken under a doctor's supervision because of the possibility of worsening hemorrhagic complications. Acetaminophen (Tylenol) and codeine may be given for severe headache and for the joint and muscle pain (myalgia). Management Do not give Aspirin because it contains at antiplatelet property which prmotes bleeding. Treatment is solely supportive and includes: * Fluids. * Analgesics (not aspirin) for fever and muscles aches. * Replacement of plasma or plasma expanders. Nursing Management Dengue is a self-limited illness but recovery might take a few weeks. Independent: Close monitoring of vital signs in critical period (between days 2 to day 7 of fever) is critical. Increased oral fluid intake is recommended to prevent dehydration. Treatment is purely concerned with relief of the symptoms (symptomatic). Dependent: Because dengue is caused by a virus, there is no specific medicine or antibiotic to treat it. Aspirin and nonsteroidal anti-inflammatory drugs should be avoided as these drugs may worsen the bleeding tendency associated with some of these infections. Acetaminophen (Tylenol) and codeine may be given for severe headache and for the joint and muscle pain (myalgia). (DHF) Oxygen and sedatives may be administered. Collaborative: A platelet transfusion is indicated in rare cases if the platelet level drops significantly (below 20,000) or if there are significant bleeding. The presence of melena or blood in the stool may indicate internal gastrointestinal bleeding requiring platelet and/or red blood cell transfusion.

Prevention of Dengue hemorrhagic fever:

Methods of prevention of Dengue hemorrhagic fever mentioned in various sources includes those listed below. This prevention information is gathered from various

sources, and may be inaccurate or incomplete. None of these methods guarantee prevention of Dengue hemorrhagic fever.

See prevention of dengue Avoid mosquito bites Mosquito repellant Protective clothing Window screens Remove water-filled mosquito breeding areas Dengue vaccine - not yet available but being researched. See also prevention of mosquito bites See also prevention of mosquito-borne diseas PATIENTS PROFILE

Name: Miss X Age: 22 Gender: Female Address: 141 Sitio Salvacion Tunasan Muntinlupa City Date of Birth: September 9, 1987 Place of Birth: Muntinlupa City Nationality: Filipino Religion: Roman Catholic Civil Status: Single Occupation: Toshiba Employee Date of Admission: Time of admission: Physician: Place of Admission: Bian Doctors Hospital Admitting Diagnosis: Dengue Fever Syndrome

A.1 CHIEF COMPLAIN Fever Patients Hx The patient complains of abdominal pain, headache, fever and general flushing of skin with on and off vomiting.

a.2 PRESENT ILLNESS Four days prior to admission, the patient had an intermittent fever associated with abdominal pain, headache, and general flushing of the

skin with on and off vomiting. A few hours prior to admission still the above sign and symptoms remain but already have (-) vomiting with accompanying chills and was diagnosed with Dengue fever Syndrome. a.3 PAST MEDICAL YEARS It was according to the patient that she wasn't been hospitalized yet not until when she was diagnosed with Dengue Fever Syndrome. Before that diagnosis, she was already experiencing fever and her mom gives her a Paracetamol for remedy.

a.4 FAMILY HISTORY According to her grandmother the only disease that the family has genetically is Diabetes Mellitus and no other diseases noted.

a.5 SOCIAL HISTORY Miss X is the daughter of Mr. and Mrs. SJ. CJS is currently working at Toshiba as an employee at Sta. Rosa Citys. Her father works as a seaman while his mother is a housewife; her grandmother is also living with them. Hence, her grandmother and her mother were the ones responsible in all the household chores. According to Miss X, she eats vegetables and fish instead she prefers eating hotdogs. Furthermore she has no vices except for computer games. After working hours, she goes directly at home to relax.

a.6 ENVIRONMENTAL HISTORY According to the patient the environment that the family has an open drainage, wherein big rats and cockroaches can be seen. The house is cleaned by her mother and grandmother. It was described by the patient that there are parts of their house that is deprived from light. C. HISTORY OF ILLNESS

During the mid of, Miss X, started experiencing fever that persist only at night. As a remedy her mom gave her Paracetamol to lower her body temperature. Except from fever shes also experiencing abdominal pain, headache and general flushing of the skin with on and off vomiting. As the above signs and symptoms persists, her parent decided to bring her to the hospital. Upon the physical assessment and after several diagnostic procedures that the patient had undergone, she was diagnosed with Dengue Fever Syndrome (DFS) and was admitted under the service of Dr. Olivares.

THEORETICAL FRAMEWORK Miss X, , was diagnosed of having Dengue Fever Syndrome (DFS).At the clinical check-up, the physician was able to identify some clinical signs of it and was referred to Dr. Olivares. The case of Miss X can be correlated with the theory of Florence Nightingale . Application Theory: The case of CJS can be correlated with the theory of Nightingale wherein, the environment of the patient is a factor leading to recovery. Having a clean, well ventilated and quite environment is important in. With a nurturing environment, the body could repair itself.

PHYSICAL ASSESSMENT (Normal Findings Actual Findings Rationale) Area Assessed 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, scars or inflammation Smooth Moist The skin springs back to its previous state after being pinched Actual Findings General flushing 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)

HEAD Size Symmetry

Inspection Inspection

Proportion to the body and the skull is rounded and smooth Symmetrical Black Curly hair, 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, 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, Evenly distributed, curved outward

Pink conjunctiva Evenly distributed Evenly distributed

Normal Normal Normal

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

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, deformities or inflammation Normal

Equal size Symmetrical Evenly distributed Light to deep brown No lesions, deformities or inflammation Normal

Normal Normal Normal Normal Due to disease Normal

GORDONS 11 FUNCTIONAL HEALTH PATTERN FUNCTION Nutrition BEFORE HOSPITALIZATION Eats 3x a day She loves to eat bread & processed foods such as hotdog, tocino, longanisa, and others. She doesnt eat vegetables and fish Seldom drinks water She is able to urinate & defecate normally everyday by herself She doesnt 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 doesnt 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

verbal & physical stimuli Health Perception She perceived Self-Perception- Perceived herself Health her health in the Self concept as a good friend, Management state of good brother & Pattern condition DAughter. Role Relationship Pattern SexualityReproductive Pattern He was able to do his responsibilities as a son & brother She thinks of having a boyfriend & getting married. She doesnt fully identifies her stressors. Her daily routine on playing computer. Her daily activities were limited in waking up in the morning to attend his class & after that going to computer shop. She 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, as a patient is not she is not aware of fully met performing her real role in this field. Same Due to her age, it is still not her priority in life Same At her age, she still has a playful mind & she doesnt mind the stressors in life. She only focuses on simple things.

Coping Stress & Tolerance Pattern Activity-Exercise Pattern

She interacts with his grandmother & other people around her Cooperates well to the doctor & nurses.

Value-Belief Pattern

Due to their culture preferences & parents influence

Anatomy And Physilology

The Circulatory System

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, is the capillaries.

The Lymphatic System

An often overlooked part of the circulatory system is the lymphatic system. As blood passes through the capillaries, some of the fluid diffuses into the surrounding tissues. One function of the lymphatic system is to collect and recycle this fluid (called lymph). Lymph passes from capillaries to lymph vessels and flows through lymph nodes that are located along the course of these vessels. Cells of the lymph nodes phagocytize, or ingest, impurities such as bacteria, old red blood cells, and toxic and cellular waste. Finally, lymph flows into the thoracic duct, a large vessel that runs parallel to the spinal column, or into the right lymphatic duct, both of which transport the lymph back into veins of the shoulder areas where is mixes with blood and is returned to the heart. All lymph vessels contain one-way valves, like the veins, to prevent backflow. The tissues of the lymphatic system include the spleen. The spleen serves as a reservoir for blood, releasing additional blood into the circulatory system as needed. It is also involved with destruction of old cells and other substances by phagocytosis. The lymphatic system is also responsible for collecting nutrients that the digestive system has extracted from our foods, and is a very important part of the immune system. We will cover the lymphatic system in detail in the lesson on the immune system.

Babyrlene P. Aabieza Edith Vizcarra RN, MAN BSN 4A Clinical Instructor

Miss

Journal of Ultrastructural studies on dengue virus type 2 infection of cultured human monocytes
Background Early interaction of dengue virus and monocyte/macrophages could be an important feature for virus dissemination after its initial entry via the mosquito vector. Since ultrastructural analysis of this interaction has not been reported, dengue type 2 (DEN2) virus-infected human monocyte cultures were studied at 1, 2, 4 and 6 hours after infection. Results Typical dengue particles and fuzzy coated viral particles were 35 to 42 nm and 74 to 85 nm respectively. Viruses were engulfed by phagocytosis and macropicnocytosis leading to huge vacuoles and phagosomes inside the monocytes. Interaction of monocytes with DEN2 virus induced apoptosis, characterized by nuclear condensation and fragmentation, cellular shrinkage, blebbing and budding phenomena and phagocytosis of apoptotic cells by neighboring monocytes. This finding was confirmed by TUNEL. Ultrastructural features associated to DEN2 virus replication were not observed. Conclusion These data suggest that clearance of the virus by monocytes and cellular death are the main features during the initial interaction of DEN2 virus and monocytes and this could be important in the rapid elimination of the virus after infection by mosquito vector. Reference: Halstead SB, O'Rourke EJ, Allinson AC: Dengue virus and
mononuclear phagocytes. II. Identity of blood and tissue leukocytes supporting in vitro infection.

Brand name/ Generic name Acetaminophen (Paracetamol)

Classification

Action

Indication Symptomatic relief of pain and fever. Relief of headache, toothachge, back pain, dysmenorrheal, myalgias,neuralg ias, etc. 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.

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

Nursing consideration Patients with alcoholic liver disease. Impaired liver or kidney function

Brand name/ Generic name

Classification

Action . 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. tract, middle ear,paranasal sinuses, eyes, kidneys, urinary tract

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

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

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

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. Objective: >C pain scale of 7/10 >grimace noted >irritable >weakness noted Characteristic: Stabbing, 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, grimace & irritability

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

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.v. >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, 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

stomach Radiation: Radiates in the whole abdomen Relief: kapag iniipit ko tiyan ko nwawala minsan sakit >skinwarm to touch >flushed skin >temp. 38 >c dry lips

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

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

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

Independent: > Rendered sponge bath >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, loosen clothing, 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, After 45 minutes of nursing care, the patient temperature decrease from 38C to 36.8 as evidenced by normal temp and absence of flushing and cool skin

PATHOPHYSIOLOGY Predisposing Factor: -Immuno Exam compromised Result - Environment WBC 12.8 Non- predisposing Factor: - Age: Interpretation - Female Increase WBC indicates Leukocytosis can be a sign of infection.

Normal Values
5 10 x 10 ^/L

Segmenters

0.90

0.60 -0.70

Increase Segmenters indicates the presence of an acute bacterial infection or some inflammation going on inside the body Decrease Lymphocytes indicates can be sign of infection. Normal Normal

Lymphocytes Hgb Hct

0.08 116 0.35

0.20 0.40 140 -180 0.40 0.54

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

 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, Kinins) Vascular response Redness & Heat Headache, Vomiting Epistaxis, Abdominal pain
Circulatory Collapse Shock

DEATH

Discharge Planning A. Patient's Name: > C.J.S a thirteen year-old male patient, who was diagnosed with Dengue Hemorrhagic Fever. B. Diet: > Encourage nutritious foods like vegetables, meat and fruits. C. Medications: > Give acetaminophen in case the temperatures increases. > Give oresol to replace fluid in the body. D. Treatment: > Increased oral fluid intake. E. Health Teaching: > D- discuss the possible source of infection of the disease. > E- educate the family/patient on how to eliminate those vectors.

> N- Never stocked water in a container without cover. > G- Gallon, container and tires must have proper way of disposal. > U- Use insecticides at home to kill or reduce mosquito. > E- Encourage the family of the patient to clean the surroundings to destroy the breeding places of mosquito.