Holy Infant College

College of Nursing

CASE PRESENTATION ON:

DENGUE FEVER WITH WARNING
SIGNS

Presented by: Group

Maceda, Johanna B.

Mesa, Leo Adrian L.

Thompson, Nikolas B.

Villanueva, Janine A.

Submitted to:

Mr. Gerald J. Develos RN

Clinical Instructor
GENERAL OBJECTIVES:

After presentation and discussion of the case, the student’s knowledge of the specific disease;
Dengue fever with warning signs will be enhanced and further understood through
comprehensive, detailed, and accurate history taking, Gordon’s typology of 11 functional health
patterns, explanation of the disease process, interpretation of laboratory result, explication of
pathophysiology and the different treatment modalities given to the patient

SPECIFIC OBJECTIVES:

 To accurately present the patient’s biographical profile along with a comprehensive

nursing history
 To present both normal and the abnormal findings of the physical assessment done to the
patient
 To present the patient’s responses to each of the given basis of the Gordon’s Typology of
11 functional health patterns
 To interpret and relay the different laboratory test and result to the disease process of the
patient
 To analyze the related anatomy and physiology of the case that is to be presented
 To explain the pathophysiology of the disease using a schematic diagram
 To identify proper, appropriate and prioritized nursing interventions for the patients
 To evaluate the patient’s responses to treatment and interventions given
 To determine and discuss the prognosis and recommendations for the clients
 INTRODUCTION

DENGUE FEVER:

Acute febrile disease caused by infection with one of the serotypes of dengue virus, which is
transmitted by mosquito Aedes aegypti, and more rarely by aedes albopictus.

Dengue is a systematic and dynamic disease. It has a wide clinical spectrum that includes both
severe and non-severe clinical manifestations. After the incubation period, the illness begins
abruptly and is followed by three phases– febrile, critical and recovery

PHASES OF DENGUE FEVER:

FEBRILE PHASE-Dehydration, high fever may cause neurological disturbances and febrile
seizures in young children

CRITICAL PHASE-Shock from plasma leakage, severe hemorrhage, organ impairment

RECOVERY PHASE-Hypervolemia (only if intravenous fluid therapy has been excessive and/or
has extended into this period)

MORBIDITY AND MORTALITY:

Global burden of dengue

The incidence of dengue has grown dramatically around the world in recent decades. Over 2.5
billion people – over 40% of the world's population – are now at risk from dengue. WHO
currently estimates there may be 50–100 million dengue infections worldwide every year.
PHILIPPINES
The DOH has a total of 106, 630 reported dengue cases nationwide from the month of
January 1- 29, 2019. The majority of the confirmed dengue cases were from the following
regions: Region II, IX, XI, and NCR. Age of Confirmed Dengue cases ranged from less than
1 year old to 80 years old. Majority of the confirmed cases were male. 31% of the confirmed
cases belonged to the 5-9 years age group. There were 456 deaths reported from January 1 to
June 29, 2019. The case fatality is lowered compared to the same period last year, 317 deaths.
MOTHER OF MERCY HOSPITAL
Mother of Mercy Hospital has a total of 56 reported cases of dengue fever from the month of
August 2019

EPIDEMIOLOGY:

Some 1.8 billion (more than 70%) of the population at risk for dengue worldwide live in member
states of the WHO South-East Asia and Western Pacific Region which bear nearly 75% of the
current global disease burden due to dengue. Asia Pacific Dengue Plan for both regions have
been prepared in consultation with member countries and development partners in response to
the increasing threat from dengue, which is spreading to new geographical areas and causing
high mortality

DENGUE PREVENTION AND CONTROL PROGRAM (DOH)

The national dengue prevention and control program was first initiated by the Department of
Health in 1993. region VII and the National Capital Region served as the pilot sites. It was not
until 1998 when the program was implemented nationwide. The target populations of the
program are the general population, the local government units, and the local health workers
VISION:
Dengue Risk-Free Philippines
MISSION:
To improve the quality of health in Filipinos by adopting an integrated dengue control approach
in the prevention and control of dengue infection
GOAL:
Reduce morbidity and mortality from dengue infection by preventing the transmission of the
virus from the mosquito vector human
OBJECTIVES:
The objectives of the program are categorized into three: health status objectives, risk reduction
objectives and services and protection objectives

PERIOD OF COMMUNICABILITY:
Patients are usually infective to the mosquito from a day before and the febrile period to the end
of it. The mosquito becomes infective from day 8 to 12 the blood meal and remains infective
throughout life.

INCIDENCE:
Dengue fever may occur at any age, but it is common among children and peaks between four to
nine years old, both sex (male and female) can be affected, it is more frequent during rainy
season, and dengue fever is more prevalent in urban communities.

TRANSMISSION:
The mosquito species, Aedes aegypti is the primary vector of dengue. The virus is transmitted to
humans through the bites of infected female Aedes mosquitoes. After virus incubation for 4–10
days, an infected mosquito is capable of transmitting the virus for the rest of its life. Infected
humans are the main carriers and multipliers of the virus, serving as a source of the virus for
uninfected mosquitoes. Patients who are already infected with the dengue virus can transmit the
infection (for 4–5 days; maximum 12) via Aedes mosquitoes after their first symptoms appear.
The Aedes aegypti mosquito lives in urban habitats and breeds mostly in man-made containers.
The peak biting time for Ae. aegypti is early morning and in the evening before dusk. Female
Ae. aegypti bites multiple people during each feeding period. The mosquito rests indoors, in
closets and other dark places. Outside, they rest where it is cool and shaded. The female
mosquito lays her eggs in water containers in and around houses, schools and other areas in
towns or villages. These eggs become adult in about 10 days. Aedes albopictus (known as tiger
mosquito in Asia), a secondary dengue vector in Asia, has spread to North America and Europe
largely due to the international trade in used tires (a breeding habitat) and other goods (e.g. lucky
bamboo). Ae. albopictus is highly adaptive and therefore can survive in cooler temperate regions
of Europe. Its spread is due to its tolerance to temperatures below freezing, hibernation, and
ability to shelter in microhabitats.
CLASSIFICATION ACCORDING TO SEVERITY:
GRADE 1
There is fever accompanied with non-specific constitutional symptoms and the only hemorrhagic
manifestation is positive in tourniquet test.
GRADE II
All signs of grade 1, plus spontaneous bleeding from the nose, gums and GIT are present
GRADE 111
There is the presence circulatory failure, as manifested by weak pulse, narrow pulse pressure,
hypotension, cold, clammy skin, and restlessness
GRADE 1V
There is profound shock, and undetectable blood pressure and pulse
PROBABLE DENGUE
People who live in/travel to dengue endemic area may experience fever and 2 of the following
criteria: nausea, vomiting, rash, joint pains, positive tourniquet test and leukopenia.
WARNING SIGNS
Warning signs for dengue fever includes abdominal pain or tenderness persistent vomiting,
lethargy, restlessness and laboratory test may result to increase in HCT concurrent with rapid
decrease in platelet count.
CRITERIA FOR SEVERE DENGUE
Severe plasma leakage leading to shock and fluid accumulation with respiratory distress.
Impaired consciousness. The incubation period is three to fourteen days, commonly seven to ten
days.
CLINICAL MANIFESTATIONS
Prodromal symptoms characterized by malaise and anorexia up to 12 hours. Fever and chills
accompanied by severe frontal headache, ocular pain, myalgia with sever backache, and
arthralgia. Nausea and vomiting. Fever persists for three to seven days. Rash is more prominent
on the extremities and the trunk. It may involve the face in some isolated cases like Petechiae
usually appears near the end of the febrile period and the most commonly on the lower
extremities. Warning signs occur 3–7 days after the first symptoms in conjunction with a
decrease in temperature (below 38°C/100°F) and include severe abdominal pain, persistent
vomiting, rapid breathing, bleeding gums, fatigue, restlessness and blood in vomit.
DIAGNOSTIC TESTS
Tourniquet test,Platelet count (decreased) for confirmatory test. Hemoconcentration increase of
at least 20% ,NS1 antigen test (nonstructural protein 1) It allows rapid detection on the first day
of fever, before antibodies appear some 5 or more days later. Positive IgM and IgG tests
for dengue antibodies detected in an initial blood sample mean that it is likely that the person
became infected with dengue virus within recent weeks. If the IgG is positive but the IgM is low
or negative, then it is likely that the person had an infection sometime in the past.
SOURCES OF INFECTION
Infected person the virus is present in the blood of patients during the acute phase of the disease
and will become a reservoir of the virus, sucked by the mosquitoes, which may then transmit the
disease. Stagnant water in the household and its premises are usual breeding place of these
mosquitoes.
TREATMENT MODALITIES
There is no effective antiviral therapy for dengue fever. Treatment is entirely symptomatic.
Analgesic drugs other than aspirin may be required for relief from headache, pain and myalgia.
Initial phase may require intravenous infusion to prevent dehydration and replacement of plasma.
Blood transfusion is indicated in patients with severe bleeding, oxygen therapy is indicated for
all patients in shock and sedatives may be needed to allay anxiety and apprehension.
PREVENTION AND CONTROL
Cover water drums and water pails at all times to prevent mosquitoes from breeding. Replace
water in flower vases once a week. Clean all water containers once a week. Scrub the sides well
to remove eggs of mosquitoes sticking to the sides. Clean gutters of leaves and debris so that rain
water will not collect as breeding places of mosquitoes. Old tires used as roof support should be
punctured or cut to avoid accumulation of water. Collect and dispose all unusable tin cans, jars,
bottles and other items that can collect and hold water. Fogging, In Southeast Asia, most
countries use insecticide spray to kill adult mosquitoes as a major way of prevention of dengue
fever. However, literature review and studies in Asia, Central and South America, and Caribbean
area, have shown that the effectiveness of this method targeting adult mosquitoes for prevention
of dengue fever is very limited
 PATIENT’S PROFILE
For adherence of the principle of confidentiality of the patient we will be addressing the patient
alias “Patient R”
Patient R, 30 years of age Male, Married, Filipino Citizen was born on October 31, 1988, Roman
Catholic, works as a government employee (Firefighter), Source of medical care is in MMH
under the care of Dr. Luchie Tan. Patient was admitted on September 2, 2019 11:00pm with a
chief complaint of Fever
Diagnosis: Dengue Fever with Warning Signs

History of Present Illness:

2 days PTA Patient felt sudden onset of intermittent fever associated with headache,
muscle pain and poor appetite and diarrhea while at work in BFP Biliran, the area has stagnant
water near his workplace and has reported cases of dengue fever. Patient does not use any
dengue control measures at home and at workplace. Opted consult at Biliran provincial hospital
dengue rapid test and stool exam was done which revealed reactive for NS1ag and positive for
amoebiasis. Patient went to MMH after confirmation of positive DRT and was admitted with
initial vital signs of BP: 120/80 mmHg HR:110BPM (brachial pulse) RR:20 CPM and
temperature of 38.3C. Tepid Sponge Bath was done to lower body temperature, patient was also
instructed to wear thin loose clothing, imparted health teachings as to prevention and control of
dengue and medication was given as ordered.
Past Medical History:
Patient has no history of DM, HPN and has no allergies to antibiotics and foods
Patient has history of dengue last 2007 during in Naval Biliran Hospital.
Family History: Grandmother (father side) (+) DM
Grandmother (father side) (+) HPN
Psychosocial History
Patient lives with his pregnant wife. No parent or visiting relative is a smoker so patient
is not exposed to second-hand smoke at home. Patient does not smoke and does not drink any
alcoholic beverage since high school.
Environmental History
House is made of concrete that is roomy enough for the 2 of them. The house is well
ventilated and always kept tidy.
The household does not practice any preventive measures against dengue & malaria.
 PHYSICAL EXAMINATION
General Survey – Patient was examined awake, conscious and coherent with the following vital
signs:

Date assessed: September 9, 2019

Upon Admission: September 02, 2019 During Duty (September 9, 2019):

BP: 120/80 BP: 120/80
HR: 110 HR: 90BPM
RR: 20CPM
RR: 20
Temp: 37.1
Temp: 38.3

Skin: Flushed Skin, Skin is brown in color. No rashes, no lesions and good skin turgor. Client
has not developed Herman’s rash over the course of the disease. Doesn’t appear sweaty, pallor
was not noted

Head: Head is symmetric and intact, round, and in the midline. No lesions.

Eyes: Sclera is white, pinkish palpebral conjunctiva, no swelling, no lesions and no discharges.
Pupils equally round, reactive to light and accommodation. Patient has no problem with
visual acuity and does not use eyeglasses

Ears: Ears are equal in size bilaterally. Auricle, tragus, and mastoid process are not tender. No
discharges noted. Earwax in minimal amount noted. Patient has no problem with hearing
and does not use hearing aid.

Nose: Patent, nasal septum at midline, no discharges, no swelling, nose bridge is intact and no
wounds noted

Mouth and Throat: Lips moist without lesions or swelling. Moist oral mucosa
and uvula at midline and tonsils not swollen, no bleeding noted on gums, normal sized tonsils.
Soft palate light pink in color, smooth and upwardly movable Hard palate whitish in color, with a
firm texture and irregular transverse rugae. Positive gag and swallowing reflex

Neck: No masses. Supple neck. Trachea at midline, no cervical lymphadenopathy. No jugular

distention noted. Carotid artery is palpable

Breasts: No tenderness, no discharges, brownish appearance

Chest and Lungs: Symmetrical chest expansion, clear breath sounds and no wheezing and no

Crackles RR: 20 cpm

Heart: Normal rate and regular rhythm. No murmurs and thrills. (tachycardia noted during
admission PR: 110BPM brachial pulse)

Abdomen: Symmetric, soft, and non-tender, normoactive bowel sounds 10 gurgles sounds per
minute

Extremities: Symmetrical. No active lesions, full and equal pulses. Brachial pulse noted, no
edema noted, normal capillary refill (<2 seconds)
 REVIEW OF SYSTEM
Date assessed: September 9, 2019

General: Patient has no body weakness, and no fever. (Upon admission: Patient has body
weakness Fever of 38.3℃)

Skin: Flushed Skin, Skin has no rashes, no itching and no dryness.

Head-EENT: Head: no headache, no dizziness or light headedness. Eyes: Patient doesn’t use
eye glasses, no pain or redness in the eyes. Ears: Has no earache and no discharges. Patient has
no problem with hearing and does not use hearing aid. Nose and sinuses: No nasal stuffiness and
no discharges (*upon admission patient has frontal headache). Throat and Mouth: No sore
throat, no sore tongue, no bleeding gums. Positive gag and swallowing reflex Soft palate light
pink in color, smooth and upwardly movable Hard palate whitish in color, with a firm texture
and irregular transverse rugae

Neck: No neck lymphadenopathies, no lesions

Breasts: No tenderness, no lumps, no nipple discharge

Respiratory: Patient has no cough, no dyspnea, no wheezing, and no crackles

Cardiovascular: No chest pain, no palpitations, and no heart murmurs No intermittent

claudication, no leg cramps, no leg swelling No easy bruising or bleeding, no previous blood
transfusion (tachycardia noted during admission PR:110BPM brachial pulse)

Gastrointestinal: good appetite, with bowel movement, and no abdominal pain (has green loose
watery stool upon admission)

Urinary: No feeling of burning or pain on urination

Genital: No discharge and no itching, no sores and redness.

Musculoskeletal: No muscle pain, no joint pain and no stiffness (Joint pain noted upon
admission)

Neurologic: No numbness or loss of sensation, tingling or “pins and needles,” tremors or other
involuntary movements GCS 15

Accessory: Normal size liver with fatty infiltration grade I, Mild splenomegaly
 LABORATORY RESULTS

DENGUE RAPID TEST

09/02/2019
Exam Result Interpretation
NS1 Ag POSITIVE A POSITIVE NS1 indicates acute-phase infection of
dengue virus.

The NS1 antigen is typically detectable within 1 to 2

days following infection and up to 9 days following
symptom onset.

NS1 is a highly conserved gylcoprotien which appears

essential for virus viability. During infection NS1 is
transported to secretory pathways to the cell surface.

(Emergencies in Infectious Diseases; Nancy Misri

Khardori and Chand Wattal)
IgM NEGATIVE Negative results may mean that the test was done too
soon after initial exposure for antibodies to develop.
IgM antibodies are produced first and tests for these
are most effective when performed at least 7-10 days
after exposure.

(New Treatment Strategies for Dengue and Other

Flaviviral Diseases; Novartis Foundation)
IgG NEGATIVE Negative results mean that the individual tested does
not have a dengue infection and symptoms are due to
another cause, or that the level of antibody may be too
low to measure. The person may still have a dengue
infection - it may just be that it is too soon after initial
exposure to the virus to produce a detectable level of
antibody.

(New Treatment Strategies for Dengue and Other

Flaviviral Diseases;Novartis Foundation)
Urinalysis
09/03/19
Exam Results Normal Value Interpretation
Color Light Normal
Yellow
Transparency Clear Normal
pH 6.5 4 . 5-8.0 Normal
Sp. Gravity 1.005 1.000 to 1.030 Normal
ALBUMIN NEGATIVE Normal
SUGAR NEGATIVE Normal

MICROSCOPIC
09/03/19
Exam Results Normal Value Interpretation
Pus Cells 0-1/hpf Normal
RBC 0-1/hpf Normal
Epithelial Cells Rare Normal
Bacteria Occasional Normal
Amorphous Rare Normal
Urates/Phosphates
Mucus Threads Rare Normal
 HEMATOLOGY

BLOOD CHEMISTRY RESULTS

09/03/2019

Reference
Exam Results Unit Interpretation
Range

LDL-
1.83 mmol/L 0.00 – 3.90 Normal
Cholesterol

Elevated levels of liver enzymes in general

SGPT/ALT 72.2 U/L 8-33 signify some form of liver (or hepatic)
damage or injury.

Total
3.89 mmol/L 0.00-5.17 Normal
Cholesterol

A level of 100 to 125 mg/dL (5.6 to 6.9

Fasting mmol/L) means you have impaired fasting
5.95 mmol/L 3.89-5.83
Blood sugar glucose, a type of prediabetes. This increases
your risk of developing type 2 diabetes.

Having high blood glucose levels may

contribute to lowering HDL cholesterol
HDL levels. It can also increase triglyceride and
1.17 mmol/L 1.42-4.70
Cholesterol LDL levels.

Consuming a poor diet

High triglycerides are usually caused by other

conditions, such as:
 Obesity.
 Poorly controlled diabetes.
Triglycerides 1.96 Mmol/L 0-1.70  An underactive thyroid (hypothyroidism).
 Kidney disease.
 Regularly eating more calories than you burn.
 Drinking a lot of alcohol.

Low levels of uric acid in the blood

may suggest:
Blood uric
258.30 umol/L 268-482  alcoholism
acid
 liver or kidney disease
 a diet low in purines
HEMATOLOGY RESULT
09/02/19
Exam Results Unit Reference Interpretation
range
Haemoglobin 162 g/l 140-180 Normal
Haematocrit 0.45 % 0.40-0.54 Normal
RBC 5.31 x10^12/L 4.5-6.2 Normal
MCV 84.0 fL 83.9-99.1 normal
MCH 30.5 Pg 27.8-33.8 normal
MCHC 363.0 g/L 320-355 A high MCHC value is often present in
conditions where hemoglobin is more
concentrated within your red blood cells. It can
also occur in conditions where red blood cells
are fragile or destroyed, leading to hemoglobin
being present outside of the red blood cells.
Conditions that can cause high MCHC
calculations are
WBC 4.0 X10^9/L 5.0-10.0 White blood cells are manufactured in bone
marrow — the spongy tissue inside some
of your larger bones. A low white blood cell
count usually is caused by:

 Viral infections that temporarily disrupt

the work of bone marrow
 Certain disorders present at birth
(congenital) that involve diminished
bone marrow function
 Cancer or other diseases that damage
bone marrow
 Autoimmune disorders that destroy
white blood cells or bone marrow cells
 Severe infections that use up white
blood cells faster than they can be
produced
 Medications, such as antibiotics, that
destroy white blood cells
 Sarcoidosis (collections of
inflammatory cells in the body)

Neutrophils 0.67 % 0.40-0.65 Normal

Lymphocytes 0.18 % 0.20-0.25 Lymphocyte counts below the normal range can
also be temporary. They can occur after a cold
or another infection, or be caused by intense
physical exercise, severe stress, or malnutrition.
A low level can also be a sign of a condition
known as lymphocytopenia or lymphopenia.
Lymphocytopenia can be inherited, or it can be
acquired alongside certain diseases, including:
  rare inherited diseases, such as ataxia-
telangiectasia

 nerve diseases, such as multiple sclerosis

 autoimmune diseases

 AIDS, or other infectious diseases

Monocytes 0.13 % 0.02-0.06 A heightened percentage of monocytes in

your blood can be caused by:

 chronic inflammatory disease, such as

inflammatory bowel disease
 a parasitic or viral infection
 a bacterial infection in your heart
 a collagen vascular disease, such as
lupus, vasculitis, or rheumatoid arthritis
 certain types of leukemia

Eosinophils 0.02 % 0.02-0.04 Normal

Basophils 0.00 % 0.00-0.001 Normal
Platelet 132 x10^9/L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus. Dengue
virus binds to platelets in the human blood.
Vascular endothelial cells infected with Dengue
virus combines with platelets and tend to
destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)

HEMATOLOGY RESULT
09/03/19
Exam Results Unit Reference Interpretation
range
Hematocrit 0.44 % 0.40-0.54 Normal
Platelet 110 X10^9/L 150-350 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus . Dengue virus
binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus combines
with platelets and tend to destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)
HEMATOLOGY RESULT
09/04/19 5:39 AM
Exam Results Unit Reference Interpretation
range
Hematocrit 0.46 % 0.40-0.54 Normal
Platelet 90 x10^9/L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus . Dengue virus
binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus
combines with platelets and tend to destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)

HEMATOLOGY RESULT
09/04/19 10:00 PM
Exam Results Unit Reference Interpretation
range
Hematocrit 0.44 % 0.40-0.54 Normal
Platelet 55 X10^9.L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus . Dengue virus
binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus
combines with platelets and tend to destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)

HEMATOLOGY RESULT
09/05/19 6:06 AM
Exam Results Unit Reference Interpretation
range
Hematocrit 0.45 % 0.40-0.54 Normal
Platelet 56 x10^9/L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus . Dengue virus
binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus
combines with platelets and tend to destroy them.
 (Dengue Guidelines for Diagnosis, Treatment,
Prevention and Control; New edition 2009)

HEMATOLOGY RESULT
09/05/19 11:21 AM
Exam Results Unit Reference Interpretation
range
Hematocrit 0.47 % 0.40-0.54 Normal
Platelet 64 X10^9/L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus . Dengue virus
binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus
combines with platelets and tend to destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)

HEMATOLOGY RESULT
09/05/19 4:30 PM
Exam Results Unit Reference Interpretation
range
Hematocrit 0.47 % 0.40-0.54 Normal
Platelet 52 X10^9/L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus . Dengue virus
binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus
combines with platelets and tend to destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)

HEMATOLOGY RESULT
09/06/19 11:22 AM
Exam Results Unit Reference Interpretation
range
Hematocrit 0.48 % 0.40-0.54 Normal
Platelet 59 X10^9/L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus . Dengue virus
 binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus
combines with platelets and tend to destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)

HEMATOLOGY RESULT
09/06/19 5:37 PM
Exam Results Unit Reference Interpretation
range
Hematocrit 0.47 % 0.40-0.54 Normal
Platelet 66 X10^9/L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus . Dengue virus
binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus
combines with platelets and tend to destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)

HEMATOLOGY RESULT
09/06/19 10:42 AM
Exam Results Unit Reference Interpretation
range
Hematocrit 0.48 % 0.40-0.54 Normal
Platelet 62 X10^9/L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus . Dengue virus
binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus
combines with platelets and tend to destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)

HEMATOLOGY RESULT
09/07/19 5:51 AM
Exam Results Unit Reference Interpretation
range
Hematocrit 0.46 % 0.40-0.54 Normal
Platelet 70 X10^9/L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus . Dengue virus
binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus
combines with platelets and tend to destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)

HEMATOLOGY RESULT
09/07/19 10:51 AM
Exam Results Unit Reference Interpretation
range
Hematocrit 0.46 % 0.40-0.54 Normal
Platelet 82 X10^9/L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus . Dengue virus
binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus
combines with platelets and tend to destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)

HEMATOLOGY RESULT
09/07/19
Exam Results Unit Reference Interpretation
range
Hematocrit 0.49 % 0.40-0.54 Normal
Platelet 96 X10^9/L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus . Dengue virus
binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus
combines with platelets and tend to destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)
HEMATOLOGY RESULT
09/08/19 12:30 AM
Exam Results Unit Reference Interpretation
range
Hematocrit 0.47 % 0.40-0.54 Normal
Platelet 104 X10^9/L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus . Dengue virus
binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus
combines with platelets and tend to destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)

HEMATOLOGY RESULT
09/08/19 5:25 AM
Exam Results Unit Reference Interpretation
range
Hematocrit 0.47 % 0.40-0.54 Normal
Platelet 106 X10^9/L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus . Dengue virus
binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus
combines with platelets and tend to destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)

HEMATOLOGY RESULT
09/08/19 5:57 AM
Exam Results Unit Reference Interpretation
range
Hematocrit 0.46 % 0.40-0.54 Normal
Platelet 116 X10^9/L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus . Dengue virus
binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus
combines with platelets and tend to destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)
HEMATOLOGY RESULT
09/09/19 6:37 AM
Exam Results Unit Reference Interpretation
range
Hematocrit 0.46 % 0.40-0.54 Normal
Platelet 114 X10^9/L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus . Dengue virus
binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus
combines with platelets and tend to destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)

HEMATOLOGY RESULT
09/09/19 5:43 PM
Exam Results Unit Reference Interpretation
range
Hematocrit 0.47 % 0.40-0.54 Normal
Platelet 126 X10^9/L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus. Dengue virus
binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus
combines with platelets and tend to destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)

HEMATOLOGY RESULT
09/10/19 6:05 AM
Exam Results Unit Reference Interpretation
range
Hematocrit 0.49 % 0.40-0.54 Normal
Platelet 148 X10^9/L 150-450 A decrease in platelet is due to bone marrow
suppression caused by Dengue virus . Dengue virus
binds to platelets in the human blood. Vascular
endothelial cells infected with Dengue virus
combines with platelets and tend to destroy them.

(Dengue Guidelines for Diagnosis, Treatment,

Prevention and Control; New edition 2009)
 FECALYSIS

09/05/19
Result Interpretation
Color Green
Consistency Mucoid
Pus Cells 1-2/HPF
Ova of Parasite No ova parasite seen
Amoebic Cyst/ Amoebic Cyst (+)
Trophozite
 WHOLE ABDOMEN AND PROSTATE ULTRASOUND
The liver is normal in size with craniocaudal length is 14.6 cm. It has smooth borders. There is
blaa blaa a parenchymal reflectivity with mild impairment in the visualization of the wall of the
hepatic blaa and blaa portion of the liver and diaphragm. No solid for fluid-filled mass seen. The
intrahepatic ducts and extrahepatic ducts are not dilated. The common bile duct is normal in
caliber at 0.33 cm.

The gallbladder is normally distended measuring 6.2 cm (L x W). It’s wall is not thickened at 0.2
cm. The lumen is echo free showing no definite evidence of stone nor mass. The pancreas is
normal in size measuring 1.6, 1.2 and 1.2 cm for the head, body and tail respectively. No facial
mass lesson is seen. The pancreatic duct is not dilated. The spleen is mildly enlarged with splenic
index of 924. No facial parenchymal lesson is seen.

The aorta and paraaortic areas are intact. No abnormal dilatations or narrowing is seen. No
lymphadenopathies are noted.

The right kidney measures 11.5 x 5.5 cm with parenchymal thickness of 1.2 cm. The left kidney
measures 12.3 x 5.3 cm with parenchymal thickness of 1.7 cm. Both kidneys measures are
normal in size and shape with normal parenchymal echogenicity. The central echo complexes of
both kidneys are intact. No lithiases or mass lesion is seen. The resistive index (RI) of both
kidneys are normal. No suprarenal mass is noted.

The urinary bladder is physiologically distended. There is no evidence of stones nor mass
lesions. The wall is not thickened.

The prostate gland is normal in size measuring 3.6 x 3.0 x 3.2 cm with approximate weight of 18
gm. The parenchyma has a normal echopattern. No calcifications are seen. No mass is
appreciated. The anatomic capsule is intact.

IMPRESSION:

1. Normal size liver with fatty infiltration Grade I

2. Mild splenomegaly with splenic index 924
3. Normal sonogram of the gallbladder, pancreas, kidney,, urinary bladder and prostate
gland
4. No intra-abdominal mass, pleural effusion or ascites
 Hematologic System
Introduction
• The Hematologic System is made up of the Blood, the Spleen, Bone Marrow, and the Liver.

• Hematology is the study of blood and all its components.

• This is the principal system by which nutrients, elements, and more are carried to tissues.

• Blood is a type of connective tissue whose cells are suspended in a liquid matrix.

• Blood is a vital in transporting substances between body cells and the external environment,
thereby promoting homeostasis.

Spleen
• An abdominal organ involved in the production and removal of blood cells and forming part of
the immune system.

Liver
• The liver makes proteins important for blood clotting and other functions.

Bone Marrow
• a soft fatty substance in the cavities of bones, in which blood cells are produced

Blood and Blood Cells

• Whole blood is slightly heavier and three to four times more viscous than water.

• It’s cells, which form mostly in the red bone marrow, include red blood cells and white blood
cells.

• Blood also contains cellular fragments are termed “formed elements” of the blood, in contrast to
the liquid portion.

Blood Volume & Composition

• Blood volume varies with body size,

changes in fluid and electrolyte
concentrations, and the amount of adipose
tissue.

• An average-sized adult has a blood volume

of about 5.3 quarts (5 liters)
 • Men have more blood than women. Men have 1.500 galons, compared to 0.875 gallons for
women.

RED BLOOD CELLS

• Red Blood Cells, or Erythrocytes, are biconcave discs.

• This shape is an adaptation for transporting gases; it increases the surface area through which gas
can diffuse.

• The Red Blood Cell’s shape also places the cell membrane closer to oxygen-carrying
hemoglobin within the cell

• Each RBC is about one-third hemoglobin by volume. This protein imparts the color of blood.

• RBC have nuclei during their early stages of development, but extrude them as the cells mature,
providing more space for hemoglobin.

Red Blood Cell Counts

• The number of red blood cells in a cubic millimeter (mm3) of blood of blood is called the red
blood cell count.

• The typical range for adult males is 4,600,000-6,200,000 cells per mm3, and that for adult
females is 4,200,000-5,400,000 cells per mm3.

RBC Production

• RBC formation initially occurs in the yolk sac, liver, and spleen.

• After an infant is born, these cells are produced almost exclusively in the tissue lining the spaces
in bones, the red bone marrow.

• The average life span of a red blood cell is 120 days

• Negative feedback utilizing the hormone erythropoietin controls the rate of red blood cell
formation.

• The kidneys, and to a lesser extent the liver, release erythropoietin response to prolonged oxygen
deficiency.

• Destruction of RBC

• RBC are quite elastic and flexible, and they readily bend as they pass through blood vessels.

• These cells become more fragile, and they are frequently damaged simply by passing through
capillaries.

• Macrophages phagocytize and destroy damaged red blood cells, primarily in the liver and
spleen.

• Hemoglobin molecules liberated from red blood cells are broken down into subunits of heme, an
iron containing portion, and globin, a protein.

• The heme further decomposes into iron and a greenish pigment called biliverdin.

• Biliverdin is converted to an orange pigment called bilirubin.

White Blood Cells

• White Blood Cells, or

leukocytes, protect
against disease.

• Leukocytes develop
from hematopoietic
stem cells in response
to hormones

• These hormones fall into two groups – interleukins and colony-stimulating factors (CSFs).

• Interleukins are numbered, while most colony-stimulating factors are named for cell population
they stimulate.

• Blood transports white blood cells to sites of infection.

• Normally, five types of white blood cells are in circulating blood.

• They differ in size, the nature of their cytoplasm, the shape of the nucleus, and their staining
characteristics.

• Granulocytes are leukocytes with granular cytoplasm, includes neutrophils, eosinophils and
basophils.

• Agranulocytes are leukocytes without cytoplasmic granules, includes monocytes and

lymphocytes.

• Granulocytes develop in red bone marrow as do red blood cells, but have short life spans,
averaging about 12 hours.

NEUTROPHILS

• Have fine cytoplasmic granules that appear light purple in neutral stain.

• Cellular defense – phagocytosis of small pathogenic microorganisms.

• Account for 54-62% of the leukocytes in a typical blood sample from an adult.

• Cellular defense – phagocytosis of small pathogenic microorganisms

EOSINOPHILS

• Contain coarse, uniformly sized cytoplasmic granules that appear deep red in acid stain.

• Make up 1-3 % of the total number of circulating leukocytes.

• Cellular defense – phagocytosis oflarge pathogenic microorganism, such as protozoa and

parasitic worms; releases antinflammatory substance in allergic reaction

BASOPHILS

• Are similar to eosinophils in size and in the shape of their nuclei, but they have fewer, more
irregularly shaped cytoplasmic granules that become deep blue in basic stain.

• Usually account for less than 1% of the circulating leukocytes.

• Secretes heparin (anticoagulant) and histamines (important in inflammatory response)

 MONOCYTES

• The largest blood cells, are two to three times greater in diameter than red blood cells.

• They usually make up 3-9% of the leukocytes in a blood sample and live for several weeks or
even months.

• Capable of migrating out of the blood to enter tissue spaces as microphage – an aggressive
phagocytic cell capable of ingesting bacteria, cellular debris and cancerous cells

LYMPHOCYTES

• Are usually only slightly larger than red blood cells.

• These cells account for 25-33% of circulating leukocytes.

• May live for years.

• Humoral defense – secretes antibodies involved in immune system response and regulation

Functions of WBC

• WBC protects against infection in various ways.

• Some leukocytes phagocytize bacterial cells in the body, and others produce proteins (antibodies)
that destroy or disable foreign particles.

• The most mobile and active phagocytic leukocytes are neutrophils and monocytes.

• Both neutrophils and monocytes contain lysosomes, which are organelles filled with digestive
enzymes that break down organic molecules in captured bacteria.

• Eosinophils help control inflammation and allergic reaction by removing biochemicals associated
with these reactions.

• Some of the cytoplasmic granules of basophils contain a blood-clot-inhibiting substance called

heparin, and other granules contain histamine.

• Lymphocytes are important in immunity. Produces antibodies that attack specific foreign
substances that enter the body.

White Blood Cell Counts

• The number of white blood cells in a cubic millimeter of human blood, called the white blood cell
count, normally is 5,000-10,000 cells.

• A rise in the number of circulating white blood cells may indicate infection.

Blood Platelets
• Platelets, or thrombocytes, are not complete cells.

• They arise from very large cells in red bone marrow, called megakaryocytes that fragment like a
shattered plate, releasing small sections of cytoplasm (the platelets) into the circulation.

• Platelets develop from hematopoietic stem cells in response to the hormone thrombopoietin.

Blood Platelet Count

 • In normal blood, platelet count varies from 130,000 – 360,000 per mm3.

• Platelet help close breaks in damaged blood vessels and initiate formation of blood clots.

Functions of Platelet

• Platelets play an imortant role in both hemostasis and blood clotting, or coagulation.

• Hemostasis refers to the stoppage of blood flow and may occur as an end result of any one of
several body defense mechanisms.

• Blood coagulation is to plug ruptured vessels ton stop bleeding and prevent loss of a vital body
fluid.

Clotting Mechanism

Blood Plasma
 • Plasma is the liquid part of the blood.

• Plasma consists of 90% water and 10% solutes.

• Plasma proteins are the most abundant of the dissolved substances (solutes) in the plasma.

• These proteins remain in the blood and interstitial fluid and ordinarily are not used as energy
sources. Three main plasma protein groups – albumins, globulins and fibrinogen.

• Albumins are the smallest of the plasma proteins, yet account for about 60% of these proteins by
weight.

• They are synthesized in the liver and because they are so plentiful, albumins are an important
determinant of the osmotic pressure of the plasma.

• Globulins, which make up about 36% of the plasma proteins, can be further subdivided into
alpha, beta, and gamma globulins.

• The liver synthesizes alpha and beta globulins which transports lipids and fat soluble vitamins.

• Lymphatic tissues produce the gamma globulins, which are type of antibody.

• Fibrinogen, which constitutes about 4% of the plasma proteins, function in blood coagulation.

• Synthesized in the liver, fibrinogen is the largest of the plasma proteins.

Blood Types (Blood Groups)

• The ABO blood group is based on the presence of two major protein antigens on red blood cell
membranes – antigen A and antigen B.

• A person’s erythrocytes have on their surfaces one of four antigen combinations: only A, only B,
both A & B, or neither A nor B.

• The resulting ABO blood type is inherited

Rh Blood Group
• The Rh Blood Group was named after the rhesus monkey in which it was first studied.

• In humans, this group includes several Rh antigens (factors).

• The most important of these is antigen D

• If any of the antigen D and other Rh antigens

are present on the red blood cell membranes,
the blood is said to be Rh-positive.

• Conversely, if the red blood cells lack Rh

antigens, the blood cells lack Rh antigens, the
blood is called Rh-negative.

• If an Rh-negative person receives transfusion

of Rh-positive blood, the Rh-antigens will
stimulate the recipient’s antibody-producing
cells to begin producing anti-Rh antibodies.
 GORDON’S 11 FUNVTIONAL HEALTH PATTERNS

Functional Health Pattern Before Hospitalization During Hospitalization

Patient’s environment has Patient experienced fever with
Health Perception/Health stagnant water near his temp of 38.3C, with
Management workplace and has reported headache, joint pain, and
cases of dengue fever. Patient diarrhea
does nor practice any dengue
control measure at home and
at workplace
Patient is complete with his
Immunization

Last Immunization was

Hepatitis B vaccine on
November 13, 2013

No known allergies
No past surgeries

Goes to Physical Examination

annually for work purposes

Does not have any

maintenance medications but
used stress tabs

Nutritional - Metabolic Diet menu: Diet menu: DAT

Breakfast: Only drinks coffee With exception of dark-
in the morning colored foods
Lunch: Mostly eats fried
chicken from street
vendors
Dinner: No specific menu, but
mostly consists of
meat, fish, and
vegetables

No food allergies

Elimination Defecates every work Elimination pattern stays the

same before hospitalization
Does not use any laxatives
Urine output: 200-400cc/shift
Does not experience any
discomfort during elimination Amber yellow colored urine

Amber yellow colored urine No burning sensation upon

urination
“Waray man ako problema ha
pag-ihi, danay naka lima ako
pagihi ha uusa ka adlaw” – as
verbalized by the pt
 Activity – Exercise Pt exercises two hours three
hours a week. Routine consists
of jogging, BFP dozen
exercise
Does not have any problems
during exercise, no signs of
hypoxia, hypercapnia.
No abnormalities in heartbeat
during exercise, no difficulty
of breathing.
Cognitive - Perceptional Time oriented, knows about
place, person, no problem in
decision making and solving,
no difficulty in forming
sentences, no loss of memory
Patient is aware of Dengue
before hospitalization but
doesn’t practice any
preventive measure against
dengue
Sleep-Rest Pt has no difficulty in
sleeping. Sleep lasts 7 hours.
Sometimes pt experiences
headaches upon waking up
And pt reported use of stress
tabs before going to sleep
Self-Perception – Self “okay lang naman, waray ko
Concept man problema ha akon pagkita
ha akon sarili, ngan satisfied
man ako ha akon body image,
tanggap ko man guinhatag ha
akon hit ginoo” – as
verbalized by the pt
Grooms himself religiously
Role-Relationship He is the father in the family
Is satisfied with his
relationship with his wife
Family members are
cooperative
Decision makers in the family
are himself and his wife
Upon Admission: Body
weakness, Joint pain, and
Activity Intolerance due to
body weakness
Pt can perform ADLs and
ROM excercises
Time oriented, knows about
place, person, no problem in
decision making and solving,
no difficulty in forming
sentences, no loss of memory
Patient is aware and
knowledgeable about different
preventive measures of
dengue
Disturbed sleeping pattern
Goes for an afternoon nap
Does not have any problems
after waking up
Grooms himself regularly
“waray man pagbago ha akon
pagkita ha akon sarili han na
ospital ako, amo man la
gihapon” – as verbalized by
the pt
Wife took over his role during
hospitalization
 Abstinence
Sexuality – Reproductive No loss of libido

Currently inactive due to wife

being pregnant

Coping / Stress Tolerance “nagluluto ako kun na iistress Both him and his wife decides
ako” – as verbalized by the pt what to do durin his
hospitalization
Pt intakes stress tabs

Pt talks with wife when

problem arises and when
making decisions

Value - Belief Pt is Roman Catholic, goes to Pt is unable to visit the church

church every Sunday, prays due to being bedridden
before going to sleep and after
waking up