You are on page 1of 26

OBJECTIVES

General:
This case presentation aims to identify and determine the
general health problems and needs of the patient with an
admitting diagnosis of Dengue Fever. This study also intends to
help promote health and medical understanding of such condition
through the application of the nursing skills.

Specific:
To enhance knowledge and acquire more information about
Dengue Fever
To give an idea of how to render proper nursing care for
clients with this condition thus it can be applied for future
exposures of students
To gather the needed data that can help to understand how
and why the disease occurs
To identify laboratory and diagnostic studies used in Dengue
Fever
To enumerate the clinical manifestations of the disease so as
to provide prompt intervention of its occurrence

ACKNOWLEDGEMENT
First and foremost, I would like to express my sincerest
gratitude to our Almighty God for giving me the ability and chance
to finish this study and for guiding me in my everyday life and
activities.
I also wish to express my deepest gratitude to my family for
providing me everything I need and for their untiring support.
I also thank my friends for their constant encouragement.
And to the patient and his mother, I want to extend my
gratitude for their cooperation and for giving me the information I
need to finish this requirement.
It is also my pleasure to thank the Dean of College of
Nursing, Dean May Veridiano for being always considerate and
approachable and for establishing a good quality of education in
our department. And to all our instructors/faculty members, I thank
them for their guidance and all the knowledge, discipline, and
lessons they have shared to us.
Finally, I thank my most beloved teachers and those special
people who made me feel that they believe in me more than I do
to myself.

INTRODUCTION:
Background of the
Disease

Dengue Virus Infection And Dengue


Hemorrhagic Fever

Definition
Dengue fever and dengue hemorrhagic fever (DHF) are acute febrile diseases
which occur in the tropics, can be life-threatening. It occurs in tropical and sub-tropical
areas of the world. Dengue fever is a febrile illness that affects infants, young children
and adults.
Dengue is a mosquito-borne infection that in recent decades has become a
major international public health concern.
Dengue fever syndrome is the type of dengue without significant hemorrhages.
Dengue hemorrhagic fever is a severe, potentially deadly infection with gross
hemorrhages spread by certain species of mosquitoes.
Other Names
Hemorrhagic Fever or H-fever, Acute Infectious Thrombocytopenic Purpura, Dengue
Shock Syndrome, Breakbone Fever, Bonecrusher Disease, Dandy Fever,
Philippine/Thai/Singapore Hemorrhagic Fever
Etiologic Agent
four closely related virus serotypes of the genus Flavivirus, family Flaviviridae
(Dengue Virus I,II,III,IV)
three other arboviruses (Chikungunya, Onyong-nyong and West Nile Fever,
have been identified with dengue-like diseases
Mode of Transmission
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 eight to 10 days, an infected mosquito is
capable, during probing and blood feeding, of transmitting the virus for the rest of its life.

Infected female mosquitoes may also transmit the virus to their offspring by transovarial
(via the eggs) transmission
Incubation Period
The incubation period of Dengue fever is usually 5 to 6 days but may vary from 3
to 10 days.
Portal of Entry
Skin
Period of Communicability
Infected person with Dengue becomes infective to mosquitoes 6 to 12 hours
before the onset of the disease and remains up to 3 to 5 days.
The mosquito becomes infective from day 8-12 after the blood meal and remains
infective throughout life.
Pathology
- generalized vasculitis and effusion in serous cavities are important postmortem
findings among those who die in shock without evidence of gross hemorrhages.
- In frank hemorrhagic cases the upper GIT may show hemorrhages
- There is subcapsular hemorrhage of the liver with fatty metamorphosis or focal
coagulation necrosis
- There are occasional basophilic and acidophilic cells with cytoplasmic
vacuolation in the sinusoids
- There is proliferation of Kuffer cells with lymphocytic infiltration and plasma cells
around the portal area.
- The lungs show marked congestion with focal hemorrhages and blood may fill up
the alveolar spaces.
- The adrenals show stimulation of the zona fasciculate and zona reticularis do not
show much change; these findings are interpreted as a response to stress.
- Enlarged and prominent lymphoid follicles in the ileum, Peyers patches, and
mesenteric lymph nodes are described.
- In the bone marrow, maturational arrest of megakaryocytes is observed.
- In the different organs, perivascular edema and diapedesis of red blood cells are
noted.
- Immunoflourescent direct staining allows the identification and localization of
dengue antigen in the tissues of fatal cases.

Clinical Manifestations
The disease manifests as a sudden onset of severe headache, muscle and joint
pains (myalgias and arthralgiassevere pain that gives it the nickname break-bone
fever or bonecrusher disease), fever, and rash. The dengue rash is characteristically

bright red petechiae and usually appears first on the lower limbs and the chest; in some
patients, it spreads to cover most of the body. There may also be gastritis with some
combination of associated abdominal pain, nausea, vomiting, or diarrhea.
Some cases develop much milder symptoms which can be misdiagnosed as
influenza or other viral infection when no rash is present. Thus travelers from tropical
areas may pass on dengue inadvertently, having not been properly diagnosed at the
height of their illness. Patients with dengue can pass on the infection only through
mosquitoes or blood products and only while they are still febrile. The classic dengue
fever lasts about two to seven days, with a smaller peak of fever at the trailing end of
the disease (the so-called "biphasic pattern"). Clinically, the platelet count will drop until
the patient's temperature is normal. Cases of DHF also show higher fever, variable
hemorrhagic phenomena, thrombocytopenia, and hemoconcentration. A small
proportion of cases lead to dengue shock syndrome (DSS) which has a high mortality
rate.
DENGUE FEVER
Abrupt onset of high fever
Severe frontal headache
Pain behind the eyes(retero-orbital pain) which worsens with eye movement
Muscle and joint pains
Loss of sense of taste and appetite
Measles-like rash over chest and upper limbs
Nausea and vomiting
Minor hemorrhagic manifestations like petechiae, bleeding from nose or gums
may occur.
Lymphadenopathy with leukopenia and relative lymphocytosis are common.
Thrombocytopenia(platelet count 100x10 3) and raised transaminases occur
less frequently.
DENGUE HAEMORRHAGIC FEVER AND DENGUE SHOCK SYNDROME
Symptoms similar to dengue fever. Or history of recent fever. Illness is often
biphasic beginning with fever with symptoms as in dengue. During recovery
phase of fever patients condition worsens markedly with severe weakness,
marked restlessness, facial pallor and often diaphoresis and circumoral cyanosis,
severe continuous pain abdomen. Liver may be enlarged. Thrombocytopenia
( platelet count 100x103 ) also occurs during this phase.
Haemmorhagic phenomenon are frequent and include positive tourniquet test,
petechae, easy bruising, bleeding from venepuncture sites, epistaxis, bleeding
from mouth & gums and skin rashes.
Frequent vomiting with or without blood. Bleeding from GI tract is an ominous
sign that usually follows a prolonged period of shock. There may be signs of
plasma leakage indicated by small pleural effusion or ascites. Hepatomegaly is
common but is not accompanied by jaundice.

Patient may go into shock manifested by :Pale, cold or clammy skin,sleepiness


and restlessness,patient feels thirsty and mouth becomes dry,rapid weak pulse
and difficulty in breathing.
Complications

Encephalopathy
Liver damage
Residual brain damage
Seizures
Shock

CASE DEFINITIONS
DENGUE FEVER:
Suspect case: Acute onset and high fever of 2-7 days duration, and two or more of the
following:
Headache,retero-orbital pain, myalgia, arthralgia, rash, hemorrhagic manifestations, and
leucopenia.
Probable case: Suspect case and one or more of the following:
Occurance of confirmed cases of dengue in the same place and time. Detection of IgM
antibody. IgM antibody indicates current or recent infection and is detectable 6-7 days
after onset of illness. If available Mc- Elisa test is more specific.
Confirmed case: Suspect or probable case and one or more of the following:
Isolation of virus or detection of viral genomic sequences. fourfold rise in titres of IgG or
IgM antibody. For this at least 2 samples are to be taken- one at the time at the time of
reporting to a clinic or a hospital and second shortly before discharge . The optimum
interval between two samples should be 10 days. Although serological tests are simpler,
they can give false positive results due to cross reaction between antibodies against
dengue and other flaviviruses. Confirmatory tests are not necessary for management of
cases and should be done to confirm the aetiology of the outbreak.
DENGUE HAEMMORHAGIC FEVER
Probable or confirmed case of dengue, and
Haemorrhagic tendencies as described under DHF.
Thrombocytopenia(platelet count 100x10 3 ).Evidence of plasma leakage
due to increased vascular permeability, manifested one or more of the
following: a rise in average haematocrit for age and sex 20%, a 20% drop in
haematocrit following volume replacement compared to baseline, signs of
plasma leakage indicated by pleural effusion or ascites
( demonstrated by ultrasonography or x-ray), hypoproteinemia. Slight
elevation of liver enzymes, hypoproteinemia and low levels of C 3
complement proteins are commonly observed. Prothrombin, partial
thromboplastin, thrombin times may be prolonged in many cases. While a
normal WBC count or leukopenia with neutrophils predominating is common
initially, a relative lymphocytosis with more than 15% atypical lymphocytes is
common when fever subsides.
DENGUE SHOCK SYNDROME
All the criteria for DHF
Evidence of circulatory failure as detailed under DSS

Classification
o Severe, frank type
With flushing, sudden high fever, severe hemorrhage, followed by sudden drop of
temperature, shock and terminating in recovery or death.
o Moderate
With high fever, but less hemorrhage, no shock
o Mild
With slight fever, with or without petechial hemorrhage but epidemiologically
related to typical cases usually discovered in the course of investigation of typical
cases.
Diagnosis
A physical examination may reveal:

Enlarged liver (hepatomegaly)


Low blood pressure
Rash
Red eyes
Red throat
Swollen glands
Weak, rapid pulse

Tests may include:


Arterial blood gases
Coagulation studies
Electrolytes
Hematocrit
Liver enzymes
Platelet count
Serologic studies (demonstrate antibodies to Dengue viruses)
Serum studies from samples taken during acute illness and convalescence
(increase in titer to Dengue antigen)
Tourniquet test/Rumpel Leads Test (causes petechiae to form below the
tourniquet)
X-ray of the chest (may demonstrate pleural effusion)

Nursing Management
Any disease or condition associated with hemorrhage is enough cause for alarm.
Immediate control of hemorrhage and close observation of the patient for vital signs

leading to shock are the nurses primary concern. Nursing measures are directed
towards the symptoms as they occur but immediate medical attention must be sought:
For Hemorrhage
- Keep the patient at rest during bleeding episodes.
- For nose bleeding, maintain 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
- If transfusion is given, support the patient during the therapy.
- Observe signs of deterioration(shock) such as low pulse, cold clammy
perspiration, prostration.
For Shock
- Prevention is the best treatment
- Dorsal recumbent position facilitates circulation
- Adequate preparation of the patient, mentally and physically prevents
accurrence of shock.
- Provision of warmth through lightweight covers (overheating causes
vasodilation which aggravates bleeding)
Diet
- Low fat, low fiber, non-irritating, non-carbonated
- Noodle soup may be given
For Fever
- Cooling measures(tepid sponge bath)
- Administer prescribed drugs
- Encourage fluid intake unless contraindicated
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.

Personal
Background of the
Patient

PERSONAL DATA
Name:

Patient X

Address:

Arayat St. Nagkaisang Nayon, Quezon City

Occupation:

none (student)

Religion:

Roman Catholic

Nationality:

Indian

DEMOGRAPHIC DATA
Date of Birth:

December 14,1996

Place of Birth:
Age:

19 years old

Gender:

Male

Civil Status:

Single

PATIENT PROFILE
Date Admitted:

May 15, 2010


12:43 pm

Attending Physician:

Dr. Dominador D Wayet

Room/Ward:

Pavilion III

Hospital Record No:

495501

HOME ENVIRONMENT AND OCCUPATION


Physical Environment:

He is studying in a public school and he is


living with his parents and other siblings and
their families.He doesnt smoke or drink
alcoholic beverages.
NUTRITIONAL PATTERN

Usual Meal:

He usually eats fried foods and seldom eats


vegetables. And he usually drinks 6 glasses of
water every day.

SLEEP AND REST PATTERN


Usual Sleep Pattern:

Usually sleeps at 9 or 10 oclock in the


evening and wakes up at 6:30 in the morning.
But during hospitalization, he frequently sleep
even on daytime.

PAST HEALTH HISTORY


Past Medical History
In the year 2000, he was diagnosed with primary complex and had
taken medicines (unrecalled) for six months.
He had previous history of dog bites in the year 2002 He had his
rabies vaccines on 2002.
Medications
Paracetamol (Biogesic)
Robitusin
Vaccinations
OPV (3)
BCG (1)
DPT (3)
Measles (1)
HepaB (3) = ?unsure
Allergies
No known allergies to food and drugs

Family History
Pulmonary Tuberculosis: grandfather(paternal), father
Hypertension: mother, father, siblings

HISTORY OF PRESENT ILLNESS


Reason for seeking medical care: Persisting on and off Febrile
episodes
One week prior to admission, the patient had a night swimming with
his friends. He slept on the seashore and had a fever the next morning.
Four days PTC, the patient also experienced abdominal pain, loose
bowel movement(2x), vomiting approximately 1cup/about every after
feeding. He had self medication of Paracetamol 500mg BID.
Two days PTC, patient still has intermittent fever.
Upon admission, vomiting and diarrhea were still present on the first
two days.
D5 0.3NaCl @ KVO rate upon admission
D5 0.3NaCl x 8 (5/16/10)
D5 LR 1L (5/17/10)

PHYSICAL
EXAMINATION
Vital Signs
Temperature
Pulse
Respiration
Blood Pressure

Upon Admission
38.1C
80beats/min
38breaths/min
110/60mmHg

HEIGHT: 166cm
WEIGHT: 42kg
GENERAL
No weight loss noted
Less energy to conduct usual activities

Latest
36.5C
76beats/min
29breaths/min
90/60mmHg

Laboratory
Examinations

Hematology(5/15)
Result
WBC

1.7

RBC
Hgb
Hct
MCV

5.50
14.81
44.27
81

MCH

26.94

MCHC
Platelets

33
51

Neutrophils

39.50

Lymphocytes
Monocytes

45.50
8.90

Eosinophils

1.80

Basophils
Blood type

4.30
O

Normal
values
4.810.8x109
/L

Interpretation

Decreased: some
medications, some
autoimmune conditions,
some severe infections,
bone marrow failure, and
congenital marrow
aplasia
12
4.7-6.1x10 /L
Within normal range
13-17g/L
Within normal range
40-52%
Within normal range
82-98fl
Decreased: microcytic
anemia
28-33pg
Decreased: decreased with
iron deficiency and
thalassemia
33-36g/L
Within normal range
150Decreased:thrombocytopenic
9
400x10 /
purpura,acute leukemia,
L
aplastic anemia,and during
cancer chemotherapy
40-70%
Decreased: viral infections,
bone marrow,suppression,
primary bone marrow
sadisease
19-48%
Within normal range
2-8%
Increased: viral infections,
parasitic disease, collagen
and hemolytic disorders
3-9%
Decreased: stress, use of
some medications(ACTH,
epinephrine, thyroxine)
0-5%
Within normal range

Hematology(5/16)
Result
WBC

2.8

RBC

5.08

Hgb
Hct
MCV
MCH

13.78
41.62
82
27.14

MCHC
Platelets

33
36

Neutrophils

34.40

Lymphocytes

58.80

Monocytes

1.80

Eosinophils

0.70

Normal
values
4.810.8x10
9
/L

4.76.1x101
2
/L
13-17g/L
40-52%
82-98fl
28-33pg

Interpretation
Decreased: some
medications, some
autoimmune conditions,
some severe infections,
bone marrow failure, and
congenital marrow
aplasia
Within normal range

Within normal range


Within normal range
Within normal range
Decreased: iron deficiency
and thalassemia
33-36g/L
Within normal range
150Decreased:thrombocytopenic
400x10
purpura,acute leukemia,
9
/L
aplastic anemia,and during
cancer chemotherapy
40-70%
Decreased: viral infections,
bone marrow
suppression, primary bone
marrow
disease
19-48%
Increased: infectious
mononucleosis, viral and
some bacterial infections,
hepatitis
2-8%
Decreased: use of
corticosteroids, RA, HIV
infection
3-9%
Decreased: stress, use of

Basophils

4.30

0-5%

some
medications(ACTH,
epinephrine, thyroxine)
Within normal range

Hematology(5/17)
Result
WBC

2.2

RBC

5.28

Hgb
Hct
MCV
MCH

14.42
43.37
82
27.33

MCHC
Platelets

33
20

Neutrophils

28.10

Lymphocytes

55.50

Monocytes

8.0

Normal
values
4.810.8x10
9
/L

4.76.1x101
2
/L
13-17g/L
40-52%
82-98fl
28-33pg

Interpretation
Decreased: some
medications, some
autoimmune conditions,
some severe infections,
bone marrow failure, and
congenital marrow
aplasiab
Within normal range

Within normal range


Within normal range
Within normal range
Decreased: decreased with
iron deficiency and
thalassemia
33-36g/L
Within normal range
150Decreased:thrombocytopenic
400x10
purpura,acute leukemia,
9
/L
aplastic anemia,and during
cancer chemotherapy
40-70%
Decreased: viral infections,
bone marrow suppression,
primary bone marrowdisease
19-48%
Increased: infectious
mononucleosis, viral and
some bacterial
infections, hepatitis
2-8%
Within normal range

Eosinophils
Basophils

4.30
4.10

3-9%
0-5%

Within normal range


Within normal range

Urinalysis
Result
Color

Yellow

Sp.Gravity
Reaction
Sugar
Protein

1.020
6.5
(-)
+2

Normal
values
Lt. yellowAmber
1.015-1.030
ph 4.8-7.7
(-)
(-)

RBC
WBC
Epith.cells
Crystals
M. Threads
Urobilinogen
Nitrate
Blood
Bilirubin
Ketone
Leukocyte

0-1
0-1
Few
Few
Moderate
+1
(-)
(-)
(-)
(-)
(-)

0-2/hpf
0-5/hpf
Few/present
A.urates-few
Few/present
1.20
(-)
(-)
(-)
(-)
(-)

Interpretation
Normal
Normal
Within the Normal Range
Normal
Nephritis,Cardiac
failure,Mercury
poisoning,Bence-Jones
protein in multiple
myeloma
Febrile states Hematuria
Within the Normal Range
Within the Normal Range
Normal
Normal
mucosal surface irritations
Normal
Normal
Normal
Normal
Normal
Normal

Pathophysiology
Bite of Virus-Carrying Mosquito
Mosquito injects salivary secretion into skins blood vessel

Virus enters the bloodstream and initial replication occurs

Viremia occurs lasting until the fourth or fifth day after onset

Antibodies are produced principally against the virus


And strong immune complex reaction occurs

Immune complex produce toxic substances like histamine, serotonin, bradykinin

Injured platelet

Fever

Thrombocytopenia

Headache

Proteinuria(+2)

Prevention
and Treatment

Prevention
Vaccine development
There is no tested and approved vaccine for the dengue flavivirus. There are
many ongoing vaccine development programs. Among them is the Pediatric Dengue
Vaccine Initiative set up in 2003 with the aim of accelerating the development and
introduction of dengue vaccine(s) that are affordable and accessible to poor children in
endemic countries. Thai researchers are testing a dengue fever vaccine on 3,0005,000
human volunteers after having successfully conducted tests on animals and a small
group of human volunteers. A number of other vaccine candidates are entering phase I
or II testing.
Mosquito control and other measures
Use of mosquito repellent creams, liquids, coils, mats etc.
Wearing of full sleeve shirts and full pants with socks
Use of bednets for sleeping infants and young children during day time to
prevent mosquito bite
As Aedes aegypti breeds in containers and receptacles detection & elimination of
mosquito breeding sources is the most important activity.
Management of roof tops, porticos and sunshades
Proper covering of stored water
Reliable water supply
Observation of weekly dry day
Remove water from coolers and other small containers at least once in a week
Use aerosol during day time to prevent the bites of mosquitoes
Do not wear clothes that expose arms and legs
Children should not be allowed to play in shorts and half sleeved clothes
Use mosquito nets or mosquito repellents while sleeping during day time
Avoid too many hanging clothes
Destruction of breeding places

Treatment
Because Dengue hemorrhagic fever is caused by a virus for which there is no known
cure or vaccine, the only treatment is to treat the symptoms.
A transfusion of fresh blood or platelets can correct bleeding problems

Intravenous (IV) fluids and electrolytes are also used to correct electrolyte
imbalances
Oxygen therapy may be needed to treat abnormally low blood oxygen
Rehydration with intravenous (IV) fluids is often necessary to treat dehydration
Supportive care in an intensive care unit/environment
Aspirin and non-steroidal anti-inflammatory drugs should be avoided as these
drugs may worsen the bleeding tendency associated with some of these
infections. Patients may receive paracetamol preparations to deal with these
symptoms if dengue is suspected
Oral fluid and electrolyte to prevent and correct dehydration
Antipyretics/acetaminophen for fever
Anticonvulsant like Dilantin for convulsions
Sedatives may be needed to allay apprehension or agitation

Medical/Nursing Management
Fluid Replacement

D5 0.3NaCl @ KVO rate upon admission


D5 0.3NaCl x 8 (5/16/10)
D5 LR 1L (5/17/10)
Laboratory Tests
Hematology
Urinalysis
Medications
Paracetamol 500mg/tab q 4 for temp. 37.8C
Ascorbic Acid 500mg/tab OD
Sucralfate 1gm/tab 1 tab q 8 PO prn
Hyoscine N.Butylbromide 10mg/tab TID
Diet and Nutrition
Diet as tolerated
Avoid Dark Color Foods
Monitoring of Vital signs and signs of hemorrhage.

EVALUATION
Upon admission, the patient was diagnosed with Dengue Fever, intermittent
fever, diarrhea and vomiting were present. A D5 0.3NaCl was hooked at KVO rate.
Decreased platelet (51x109/L) count and +2proteinuria were shown on the laboratory
result. It is also shown in the results that there are decreased values of MCV and MCH
which are indicative of anemia. WBC and neutrophils were decreased while monocytes
were increased, which indicate severe viral infection. On the second day of
confinement, diarrhea and vomiting were still present. The IV fluid infusion rate was
changed to 40-41gtts/min and based on the laboratory result, the platelet count
continued to decrease to 36x10 9/L. The patient is on DAT diet with restriction on darkcolored foods. On his third day on the hospital, the patient had no fever, diarrhea and
vomiting but a great decreased on the platelet count (20x10 9/L) was noted. The patient
should be observed and closely monitored for signs and symptoms of bleeding. Health
teachings should be provided to the patient as well as to the family since they are the
primary care giver, in order to prevent the development of further complication and to
prevent any other family member from acquiring the same disease. And they should
comply with the therapeutic regimen as ordered. They should be instructed to report any
signs of bleeding to provide prompt intervention.

BIBLIOGRAPHY
Book References:
Brunner and Suddarth,s Textbook of Medical and Surgical Nursing
Tenth Edition
Suzanne C. Smeltler, Brenda G. Bare
Essentials of Anatomy and Physiology
8th Edition
Elaine Marieb

Eternal Links:
www.nlm.nih.gov/medlineplus/ency/article/000223.htm
en.wikipedia.org/wiki/Stomach_cancer
emedicine.medscape.com/article/375384-overview
www.google.com

Others:
Patients Chart