Department of Family and Community Medicine

Clinical Pathway for Dengue Fever with Warning Signs

Physician’s Admitting Order Sheet

Inclusion Criteria: DENGUE FEVER WITH WARNING SIGNS for patients 19 years old and above
Exclusion Criteria: PROBABLE DENGUE, DENGUE FEVER WITHOUT WARNING SIGNS, SEVERE DENGUE and patients
below 19 years old

Patient’s Name:
Birthday:
Hospital ID number LOS: 5 days

PHYSICIANS NOTES (DAY1) ORDERS Variance Sign

S (subjective findings/symptoms) Admit to ward 10 under the service of FAMED

Vital signs monitoring q 4hrs
Diagnostics/procedures:
 CBC
 Urinalysis
 Blood typing
 CXR-PA
O(objective findings/ lab findings)  Serial Hct/plt q 6 hrs
IVF:
 PNSS 1L at ____(5-7 ml/kg/hr) to run for 1-2hrs;
re-assess afterwards
 PNSS 1L at _____(5cc/kg/hr) then reassess after 4
hrs
 PNSS 1L at______(3cc/kg/hr)
Medications

VICENTE SOTTO MEMORIAL MEDICAL CENTER

 Paracetamol 500mg/tab 1 tab q6 as needed for
temp>38C
 Omeprazole 40mg IVTT OD
Assessment/working impression/clinical dx  Metoclopromide 10mg IVTT q8hrs as needed for
DENGUE FEVER WITH WARNING SIGNS vomiting
 Tranexamic acid 500 mg IVTT q8hours prn for
bleeding episodes.
Diet/nutrition orders:
DAT except dark colored foods and drinks

 Monitor I and O in exact figures

 Watch out for the following any signs of bleeding or
hypoperfusion
Activity/safety orders: No limit on activity
Consults orders:
Plan of care: Provide for psychosocial needs:
Admit patient Provide patient/family education on the prevention of dengue
Obtain baseline full blood count Discharge planning orders:
Vital signs monitoring Must fulfill the following criteria
Strict I&O monitoring in absolute figure Clinical
Antipyretics  No fever for 48hrs
Increase oral fluid intake  Improvement in clinical status (general well-being,
appetite, hemodynamic status, urine output, no
respiratory distress)
Laboratory
 Increasing trend of platelet count
 Stable hematocrit without IV fluids
Activated by: Acknowledge by:

/ / / /

ATTENDING PHYSICIAN/RESIDENT NURSE-IN-CHARGE

 Both AP and NIC must sign at the bottom of the pathway form to activate it
 The pathway will be discontinued by anyone whenever:

CLINICAL PATHWAY VSMMC-MSD-FAMED-CP-07

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June 15, 2018
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 1. The patient’s primary diagnosis changes
2. The patient’s condition significantly worsens
3. The patient fails to meet clinical outcomes for 24-48 hours

 Variance Codes:

A. PATIENT/FAMILY B. CLINICAL C. SYSTEM D. COMMUNITY

a.1 Non-adherence to b.1 Development of a c.1 Lack of available d.1 Unable to contact
plan of care new medical Equipment / Community Health
a.2 Patient or family /surgical problem Medicines Service
refuses discharge b.2 Exacerbation of c.2 Failure to perform a d.2 Delay in availability
a.3 Financial constraints underlying condition recommended of recommended
a.4 Home per b.3 Delay in response to procedure support
request/against medical treatment c.3 Delay in response to
medical advice interdepartmental
a.5 Absconded referral (co-
management,
consult, or transfer
of service)

VICENTE SOTTO MEMORIAL MEDICAL CENTER

CLINICAL PATHWAY VSMMC-MSD-FAMED-CP-07

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June 15, 2018
Page 2 of 6
 PHYSICIANS NOTES (DAY2) ORDERS Variance Sign
Physician’s notes
S (subjective findings/symptoms) Vital signs monitoring q 4hrs
Diagnostics/procedures:
 Serial Hct/plt q 6 hrs
IVF:
 PNSS 1L at ____(5-7 ml/kg/hr) to run for 1-
2hrs; re-assess afterwards
 PNSS 1L at _____(5cc/kg/hr) then reassess
O(objective findings/ lab findings) after 4 hrs
 PNSS 1L at______(3cc/kg/hr)
Medications
 Paracetamol 500mg/tab 1 tab q6 as needed
for temp>38C
 Omeprazole 40mg IVTT OD
 Metoclopromide 10mg IVTT q8hrs as needed
for vomiting
 Tranexamic acid 500 mg IVTT q8hours prn for
bleeding episodes
Diet/nutrition orders:
Assessment/working impression/clinical dx DAT except dark colored foods and drinks
DENGUE FEVER WITH WARNING SIGNS
 Monitor I and O in exact figures
 Watch out for the following: any signs of
bleeding or hypoperfusion
Activity/safety orders: No limit on activity
Consults orders:
Provide for psychosocial needs:
Provide patient/family education on the prevention of
dengue

VICENTE SOTTO MEMORIAL MEDICAL CENTER

Discharge planning orders:
Plan of care: Must fulfill the following criteria
Vital signs monitoring Clinical
Strict I&O monitoring in absolute figure  No fever for 48hrs
Antipyretics  Improvement in clinical status (general well-
Increase oral fluid intake being, appetite, hemodynamic status, urine
output, no respiratory distress)
Laboratory
 Increasing trend of platelet count
 Stable hematocrit without IV fluids

 Both AP and NIC must sign at the bottom of the pathway form to activate it
 The pathway will be discontinued by anyone whenever:

1. The patient’s primary diagnosis changes

2. The patient’s condition significantly worsens
3. The patient fails to meet clinical outcomes for 24-48 hours

 Variance Codes:
A. PATIENT/FAMILY B. CLINICAL C. SYSTEM D. COMMUNITY
a.1 Non-adherence to b.1 Development of a c.1 Lack of available d.1 Unable to contact
plan of care new medical Equipment / Community Health
a.2 Patient or family /surgical problem Medicines Service
refuses discharge b.2 Exacerbation of c.2 Failure to perform a d.2 Delay in availability
a.3 Financial constraints underlying condition recommended of recommended
a.4 Home per b.3 Delay in response to procedure support
request/against medical treatment c.3 Delay in response to
medical advice interdepartmental
a.5 Absconded referral (co-
management,
consult, or transfer
of service)

CLINICAL PATHWAY VSMMC-MSD-FAMED-CP-07

Revision 1
June 15, 2018
Page 3 of 6
 PHYSICIANS NOTES (DAY 3) ORDERS Variance Sign

S (subjective findings/symptoms) Vital signs monitoring q 4hrs

Diagnostics/procedures:
 Serial Hct/plt q 6 hrs

IVF:
 PNSS 1L at _____(5cc/kg/hr) then
reassess after 4 hrs
O(objective findings/ lab findings)  PNSS 1L at______(3cc/kg/hr)
Medications
 Paracetamol 500mg/tab 1 tab q6 as needed
for temp>38C
 Omeprazole 40mg IVTT OD
 Metoclopromide 10mg IVTT q8hrs as
needed for vomiting
 Tranexamic acid 500 mg IVTT q8hours prn
for bleeding episodes

Diet/nutrition orders:
Assessment/working DAT except dark colored foods and drinks
impression/clinical dx
DENGUE FEVER WITH WARNING  Monitor I and O in exact figures
SIGNS  Watch out for the following: any signs of
bleeding or hypoperfusion

Activity/safety orders: No limit on activity

Consults orders:
Provide for psychosocial needs:
Provide patient/family education on the prevention of
dengue

VICENTE SOTTO MEMORIAL MEDICAL CENTER

Discharge planning orders:
Must fulfill the following criteria
Plan of care: Clinical
Continue vital signs monitoring  No fever for 48hrs
Strict I&O monitoring in absolute  Improvement in clinical status (general well-
figure being, appetite, hemodynamic status, urine
Antipyretics output, no respiratory distress)
Increase oral fluid intake Laboratory
 Increasing trend of platelet count
 Stable hematocrit without IV fluids

 Both AP and NIC must sign at the bottom of the pathway form to activate it
 The pathway will be discontinued by anyone whenever:

1. The patient’s primary diagnosis changes

2. The patient’s condition significantly worsens
3. The patient fails to meet clinical outcomes for 24-48 hours

 Variance Codes:

A. PATIENT/FAMILY B. CLINICAL C. SYSTEM DCOMMUNITY

a.1 Non-adherence to b.1 Development of a c.1 Lack of available d.1 Unable to contact
plan of care new medical Equipment / Community Health
a.2 Patient or family /surgical problem Medicines Service
refuses discharge b.2 Exacerbation of c.2 Failure to perform a d.2 Delay in availability
a.3 Financial constraints underlying condition recommended of recommended
a.4 Home per b.3 Delay in response to procedure support
request/against medical treatment c.3 Delay in response to
medical advice interdepartmental
a.5 Absconded referral (co-
management,
consult, or transfer
of service)

CLINICAL PATHWAY VSMMC-MSD-FAMED-CP-07

Revision 1
June 15, 2018
Page 4 of 6
 PHYSICIANS NOTES (DAY 4) ORDERS Variance Sign

S (subjective findings/symptoms) Vital signs monitoring q 8hrs

Diagnostics/procedures:
 Serial Hct/plt q 12 hrs
IVF:
 PNSS 1L at______(3cc/kg/hr)
Medications
 Paracetamol 500mg/tab 1 tab q6
O(objective findings/ lab findings) as needed for temp>38C
 Omeprazole 40mg IVTT OD
 Metoclopromide 10mg IVTT q8hrs
as needed for vomiting
 Tranexamic acid 500 mg IVTT
q8hours prn for bleeding episodes

Diet/nutrition orders:
DAT except dark colored foods and drinks

 Monitor I and O in exact figures

Assessment/working impression/clinical dx  Watch out for the following: any
DENGUE FEVER WITH WARNING SIGNS signs of bleeding or hypoperfusion

Activity/safety orders: No limit on activity

Consults orders:
Provide for psychosocial needs:
Provide patient/family education on the
prevention of dengue

Discharge planning orders:

Must fulfill the following criteria
Clinical
Plan of care:  No fever for 48hrs
Continue vital signs monitoring  Improvement in clinical status

VICENTE SOTTO MEMORIAL MEDICAL CENTER

Strict I&O monitoring in absolute figure (general well-being, appetite,
Antipyretics hemodynamic status, urine output,
Increase oral fluid intake no respiratory distress)
Laboratory
 Increasing trend of platelet count
 Stable hematocrit without IV fluids

 Both AP and NIC must sign at the bottom of the pathway form to activate it
 The pathway will be discontinued by anyone whenever:

1. The patient’s primary diagnosis changes

2. The patient’s condition significantly worsens
3. The patient fails to meet clinical outcomes for 24-48 hours

 Variance Codes:

A. PATIENT/FAMILY B.CLINICAL C.SYSTEM D.COMMUNITY

a.1 Non-adherence to b.1 Development of a c.1 Lack of available d.1 Unable to contact
plan of care new medical Equipment / Community Health
a.2 Patient or family /surgical problem Medicines Service
refuses discharge b.2 Exacerbation of c.2 Failure to perform a d.2 Delay in availability
a.3 Financial constraints underlying condition recommended of recommended
a.4 Home per b.3 Delay in response to procedure support
request/against medical treatment c.3 Delay in response to
medical advice interdepartmental
a.5 Absconded referral (co-
management,
consult, or transfer
of service

CLINICAL PATHWAY VSMMC-MSD-FAMED-CP-07

Revision 1
June 15, 2018
Page 5 of 6
 PHYSICIANS NOTES (DAY 5) ORDERS Variance Sign

S (subjective findings/symptoms) May go home.

O(objective findings/ lab findings)
Assessment/working impression/clinical dx
DENGUE FEVER WITH
RESOLVING/RESOLVED
Plan of care:
Discharge patient
Give Home Medications.
Give Discharge instructions.
Discontinue serial Hct/plt monitoring.
IVF:
 PNSS to consume/terminate.
Home Medications
 Multivitamins 1 capsule once a day
Diet/nutrition orders:
 DAT
Activity/safety orders: No limit on activity
Consults orders:
 Follow-up at room 1 OPD after 3 days with
repeat CBC result.
Provide patient/family education on the prevention of
dengue
Discharge planning orders:
WARNING SIGNS, Must fulfill the following criteria
Clinical
 No fever for 48hrs
 Improvement in clinical status (general
well-being, appetite, hemodynamic status,
urine output, no respiratory distress)
Laboratory
 Increasing trend of platelet count
 Stable hematocrit without IV fluids

VICENTE SOTTO MEMORIAL MEDICAL CENTER

 Both AP and NIC must sign at the bottom of the pathway form to activate it
 The pathway will be discontinued by anyone whenever:

1. The patient’s primary diagnosis changes

2. The patient’s condition significantly worsens
3. The patient fails to meet clinical outcomes for 24-48 hours

 Variance Codes:

A. PATIENT/FAMILY B.CLINICAL C.SYSTEM D.COMMUNITY

a.1 Non-adherence to b.1 Development of a c.1 Lack of available d.1 Unable to contact
plan of care new medical Equipment / Community Health
a.2 Patient or family /surgical problem Medicines Service
refuses discharge b.2 Exacerbation of c.2 Failure to perform a d.2 Delay in availability
a.3 Financial constraints underlying condition recommended of recommended
a.4 Home per b.3 Delay in response to procedure support
request/against medical treatment c.3 Delay in response to
medical advice interdepartmental
a.5 Absconded referral (co-
management,
consult, or transfer
of service)

Prepared by: Date: Reviewed by: Date: Approved by: Date:

Grace N. Melchor, MD, FPAFP Antonio Roque R. Paradela,MD, FPCS Gerardo M. Aquino JR., MD, MHA, CEO VI
Chairman Chief, Medical Professional Staff II Medical Center Chief II
Family Medicine Department

CLINICAL PATHWAY VSMMC-MSD-FAMED-CP-07

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June 15, 2018
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