Ateneo de Naga University

College of Nursing

CASE STUDY
Dengue

Submitted by:
Kathleen F. Vargas
RLE- Group 2
ADNU- BSN 2

Submitted to:
Dennis Locsin RN.,MN.,MAN
 I. Definition of the Case

My designated RLE Group and I were at St. John Hospital for this rotation. In this
clinical area, we are expected to monitor and to record the vital signs of our respective
patients. In addition, we also carried out some doctor's orders such oral medication
administration and charting in the patient’s chart. The case that I've handled in the clinical
area is very common because most of the admitted clients in the hospital have the same
chief complaint. For this case study, the case that I'll be using is the disease that has been
diagnosed to my patient, which is Dengue.

Dengue is a very common disease and a public health concern in the world especially
in the remote areas due to the increasing numbers of mosquitoes. Dengue fever is a
multisystem disorder caused due to infection of Dengue virus which is the single positive-
stranded RNA virus (Rodenhuis et. al, 2010; WHO 2009). The transmission of virus occurs
via mosquitoes which are possessed in the increased number of stagnant water and also
causes by the poor sanitation of the place.

The patient could manifest systemic symptoms such as body malaise, high body
temperature, low platelet count, skin rashes and acute muscle pain distinctive to warmth,
narrow pulse rate and erythema and clinical diagnosis of Dengue may also vary from being
asymptomatic to very severe fever. These clinical manifestations were present in the patient.
Minority of patients end up progressing to a more severe form of shock or hemorrhagic fever
due to the decreasing number of platelet count which includes additional haematological
manifestations like pancytopenia bleeding and severe hypotension secondary to septic shock
(WHO 2009).

The significant learning or insight that I had during this rotation in St. John Hospital
is that, as nurses, we should be able to monitor the conditions of the patients that we are
assigned to. With our help, the conditions of our patients could improve and that they could
feel better. We should also remind them to comply with the necessary medications that their
physician prescribed because it is important for their well-being.
 II. Case Details (Patient profile, interventions and outcome)

Patient is a 2 year old female who was diagnosed to have Dengue Fever with a chief
complaint of fever for 3 days with an evident skin rashes, body malaise, increased body
temperature, decreased platelet count and watery stool. Young children and people infected
for the first time typically have milder symptoms than older children and adults.

 Name: Garcia, Rylee Chloe F.

 Age: 2 y/o
 Address: Azucena St. Concepcion Pequena Naga City
 Birthdate: June 14, 2017
 Race: Filipino
 Religion: Roman Catholic

Focus #1 is Ineffective Thermoregulation with a body temperature of 38.1 degrees

Celsius, positive for coughing, with skin rashes and positive for irritability. The nursing
interventions was to administered paracetamol every four hours for fever, monitored the
pulse rate and body temperature and advised to always stay with the client most of the time
especially that the client is still young. Then Focus #2 is Fluid Volume Deficit because of the
positive watery stool of the patient, the nursing interventions would be advised the
significant other of the patient to increase the fluid intake of the baby and monitor the input
and output of the client. After the nursing interventions the temperature of the client was
reduced from 38.1 degree Celsius to 37.3 degree Celsius but watery stool is still noted.

III. Body Systems affected by Dengue Virus

Dengue Virus attacks the immune system of the body to get around its defenses and
infect more cells in the body. As the infected monocytes travel through the lymphatic system
and it spreads in the entire body systems including cells in the lymph nodes, macrophages in
liver and spleen, bone marrow and monocytes in the blood. Due to the dengue virus that
spreads throughout the body systems, it may result to viremia which is a condition that has a
high level of the dengue virus in the bloodstream. But the immune system of our body has
its own defenses to fight the dengue virus, as the virus spreads throughout the body system,
the infected cells releases small proteins that are part of the large group of proteins which is
the cytokines, called interferons it has the ability to interfere with viral replication and they
activate the innate immune system defenses. Interferons help the immune system to
recognize cells that are infected by the dengue virus and help to protect the uninfected cells
from the spread of virus. The increase of body temperature that can lead to severe fever is
the defense of the immune system from the virus.

IV. Pathophysiology of Dengue

Aedes aegypti Aedes albopictus

Dengue Virus

Increased Vascular Permeability Low Platelet Count

Plasma leakage Coagulation of Blood

(Hemorrhagic Dengue
Fever)
Severe Bleeding

Shock

DEATH
 Dengue virus is a viral disease caused by antigenically serotypes dengue virus
(DENV) each of them has a unique host immune response to the virus which are the Dengue
Virus DENV-1, DENV-2, DENV-3, DENV-4 and the newest DENV-5 are the classifications of
Dengue Virus that is transmitted to non-human primates and human form via mosquito
vector, specifically the Aedes aegypti and Aedes albopictus. With just one dengue serotype
associated to the infection grant lifelong homotypic immunity. Clinical manifestations of
Dengue Virus range from asymptomatic infection to unstable body temperature that leads to
severe dengue fever and if the fever was gone and goes beyond the normal range of body
temperature but the platelet count decreases it may lead to hemorrhagic fever and would be
possible for blood transfusion if the thrombocytopenia with platelet counts ≤ 100 ×
109/L and plasma leakage due to increased vascular permeability evidenced by
hemoconcentration, pleural effusion and ascites.

V. Signs and Symptoms

Primary signs of dengue virus are shock, dehydration, bleeding and any organ failure
and the symptoms appear 3-15 days after a mosquito bite and it appears to have high fever,
severe muscle and joint pain with a severe headache. Other symptoms would be rashes,
mild bleeding, lymph nodes of the neck and groin may be swollen. Dengue fever may lead to
Dengue hemorrhagic fever if left untreated that starts with the typical signs and symptoms
of dengue as described above but the fever lasts for seven days and symptoms occur that
are related to increased permeability of the capillary blood vessels. These symptoms can
include chills, nausea, loss of appetite, easy bruising, nosebleeds, bleeding gums, skin
hemorrhages, severe abdominal pain, prolonged vomiting, breathing problems, and even
internal bleeding may occur. The disease may progress to failure of the circulatory system,
leading to shock and death. But young children and people infected for the first time typically
have milder symptoms than older children and adults.
VI. Nursing Management

Assessment of a patient with Dengue should include:

 Assessment of the general condition

 Assessment of the patient’s heart rate, temperature, pulse pressure and blood
pressure.
 Evaluation of Input and Output
 Assessment of evidence of bleeding and rashes.

Nursing Diagnosis

Based on the assessment, patient with Dengue is diagnosed with:

 Fluid Volume Deficit

 Ineffective Thermoregulation
 Risk for bleeding
 Risk for shock
 Body malaise
 Decreased Platelet Count

Nursing Care Planning and Goals

The goals in a patient with Dengue are:

 Be afebrile and show no signs of infection.

 Show RBC, WBC, HCT and Platelet count results within the normal range.
 Increased fluid intake and maintain at a functional level.
 Report pain relieved.

Nursing Interventions

 Assessed patient’s general condition and the level of comfort

 Monitored Vital Signs
 Advised to stay with the patient most of the time
 Encouraged to increase fluid intake
  Due medications are given as per doctor’s order
 Provided enough rest and sleep
 Tepid Sponge Bath done
 Monitored client’s report of pain in specific areas, whether pain is increasing, diffused,
or localized.
 Placed the patient in Trendelenburg position to restore blood volume to the head.
 Avoid Dark Colored Food

VII. Medication and Treatment

There is no specific medication for Dengue but the doctor may advise the patient to
increase fluid intake and have an adequate rest and sleep and if there is a fever the doctor
will order the patient to take Paracetamol. Avoid medicines with aspirin, which could worsen
bleeding and advise the patient to eat food rich in Vitamin K.

Paracetamol

Uses

Paracetamol is a pain reliever and a fever reducer. The exact mechanism of action of is
not known. Paracetamol is used to treat many conditions such as headache, muscle
aches, arthritis, backache, toothaches, colds, and fevers.

Indication

Mild to moderate pain and fever.

Dosage

Oral (Child)

Fever, Mild to moderate pain

Child: 1-2 months 30-60 mg 8 hourly. Max: 60 mg/kg/day; 3-<6 months 60 mg. 6
months to <2 years 120 mg; 2-<4 years 180 mg; 4-<6 years 240 mg; 6-<8 years 240 or
250 mg; 8-<10 years 360 or 375 mg; 10-<12 years 480 or 500 mg; 12-16 years 480 or
750mg. Administer 4-6 hourly if necessary. Max: 4 doses in 24 hours.
 Administration

May be taken with or without food.

Contraindications

Hypersensitivity, Severe hepatic impairment or active liver disease (IV)

Adverse Drug Reactions

Adverse Drug Reactions

Significant: Thrombocytopenia, leukopenia, neutropenia, pancytopenia,

methaemoglobinaemia, agranulocytosis, angioedema, pain and burning sensation at injection
site. Rarely, hypotension and tachycardia.

Gastrointestinal disorders: Nausea, vomiting, constipation.

Nervous system disorders: Headache.

Psychiatric disorders: Insomnia.

Skin and subcutaneous tissue disorders: Erythema, flushing, pruritus.

Potentially Fatal: Hepatotoxicity, acute renal tubular necrosis. Rarely, hypersensitivity

reactions such as acute generalised exanthematous pustulosis (AGEP), Stevens-Johnson
syndrome (SJS), toxic epidermal necrolysis (TEN).Gastrointestinal disorders: Nausea,
vomiting, constipation.

Nervous system disorders: Headache.

Psychiatric disorders: Insomnia.

Skin and subcutaneous tissue disorders: Erythema, flushing, pruritus.

Potentially Fatal: Hepatotoxicity, acute renal tubular necrosis. Rarely, hypersensitivity

reactions such as acute generalised exanthematous pustulosis (AGEP), Stevens-Johnson
syndrome (SJS), toxic epidermal necrolysis (TEN).
 Drug Interaction

Decreased absorption with colestyramine, decreased serum concentrations with

rifampicin and some anticonvulsants (e.g. phenytoin, phenobarbital, carbamazepine,
primidone). Enhances the anticoagulant effect of warfarin and other coumarins with
prolonged use. Increased absorption with metoclopramide and domperidone. Increased
serum concentration with probenecid. May increase serum concentration of chloramphenicol.

Mechanism of Action

Description: Paracetamol exhibits analgesic action by peripheral blockage of pain impulse

generation. It produces antipyresis by inhibiting the hypothalamic heat-regulating centre. Its
weak anti-inflammatory activity is related to inhibition of prostaglandin synthesis in the CNS.

Synonym: acetaminophen.

Onset: Oral: <1 hour. IV: 5-10 minutes (analgesia); within 30 minutes (antipyretic).

Duration: Oral, IV: 4-6 hours (analgesia). IV: ≥6 hours (antipyretic).

Pharmacokinetics:

Absorption: Well absorbed after oral and rectal administration.

Time to peak plasma concentration: Approx 10-60 minutes (oral); 15 minutes (IV);
approx 2-3 hours (rectal).

Distribution: Distributed into most body tissues. Crosses placenta and enters breast milk.
Plasma protein binding: Approx 10-25%.

Metabolism: Mainly metabolised in the liver via glucuronic and sulfuric acid conjugation.
N-acetyl-p-benzoquinone imine (NAPQI), a minor metabolite produced by CYP2E1 and
CYP3A4, is further metabolised via conjugation with glutathione in the liver and kidneys.

Excretion: Mainly via urine (<5% as unchanged drug; 60-80% as glucuronide

metabolites and 20-30% as sulphate metabolites). Elimination half-life: Approx 1-3 hours.
 VIII. Evaluation

After the nursing interventions, the patient has achieved the following:

 The patient is afebrile.

 Watery stool is still noted
 Absence of rashes and bleeding
 Decreased platelet count.
 Reported pain is relieved or controlled.

References

Dengue. (2019, June 19). Retrieved from https://emedicine.medscape.com/article/215840-

overview#a3

Dengue Fever: Symptoms, Causes, and Treatments. (n.d.). Retrieved from

https://www.webmd.com/a-to-z-guides/dengue-fever-reference#1

Tangnararatchakit, K. (2006, November 14). Pathophysiology and management of dengue

hemorrhagic fever. Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1111/j.1778-
428X.2006.00025.x

(n.d.). Retrieved from

https://www.mims.com/philippines/drug/info/paracetamol/?type=brief&mtype=generic