Lyceum- Northwestern University College of Nursing Tapuac District, Dagupan City Case Study on Dengue Fever Submitted to: Ma. Lourdes Amistad Submitted by: Table of Contents I. Introduction II. Objectives III. Patient·s Profile IV. Patient·s History V. Physical Assessment VI. Laboratory Data VII. Anatomy & Physiology VIII. Pathophysiology IX. Medical and Surgical Management X. Nursing Management -Nursing Care Plan -Drug Study XI. Discharge Planning Introduction Dengue Fever and Dengue Hemorrhagic fever are acute febrile diseases transmitted by mosquitoes, which occur in the tropics, can be life-threatening and are caused by four closely related virus serotypes of the genus Flavivirus, family Flaviviridae. It was identified and named in 1779. It is also known as breakbone fever, since it can be extremely painful. Unlike malaria, dengue is just as prevalent in the urban districts of its range as in rural areas. Each serotype is sufficiently different that there is no cross-protection and epidemics caused by multiple serotypes (hyperendemicity) can occur. Dengue is transmitted to humans by the Aedes (Stegomyla) aegypti or more rarely the Aedes albopictus mosquito. The mosquitoes that spread dengue usually bite at dust and dawn but may bite at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. The WHO says some 2.5 billion people, two fifths of the world·s population, are now at risk from dengue and estimates that there may be 50 million cases of dengue infection worldwide every year. The disease is now endemic in more than 100 countries. Objectives A. General Objectives Our general objective is to understand what Dengue fever, Hemorrhagic fever is and to acquire adequate and positive attitude in the case of a client with Dengue Fever and Dengue Hemorrhagic Fever. This case study aims to identify and determine the general health problems and needs of the patient with an admitting diagnosis of Dengue fever or Dengue Hemorrhagic Fever. This also intends to help patients promote health and medical understanding of such condition through the application of the nursing skills. B. Specific Objectives y To know how to prevent and control the transmission of Dengue virus and obtain reduction or to reduce the morbidity and mortality rates of Dengue infection to a level where in it will no longer be a public health problem. y To raise the level of awareness of patients with health problems that she/he may encounter. y To facilitate the patient in taking necessary action to solve and prevent the identified problem on her own. y To help the patient in motivating him/her to continue the health care provided by the health worker. y To render nursing care information to the patient through the application of the nursing skills. Management of Dengue Fever Dengue hemorrhagic fever is a serious viral disease that is generally associated with severe febrile symptoms (extremely high fevers). With appropriate medical care, the mortality rate of dengue fever is relatively low. It is a disease that can be managed fairly well with simple treatment. Without treatment, however, the mortality rate for those infected with dengue hemorrhagic fever is greatly increased. Types There are actually several different types of dengue hemorrhagic fever. All manifestations of it are caused by one of four related viruses. These viruses all belong to the Flaviviridae family. In most instances, diagnosis of dengue hemorrhagic fever doesn't include determination of which of the four viruses is responsible for the infection. Treatment and management of dengue is identical regardless of the exact type of virus that is responsible. Time Frame Management and treatment of dengue fever should be undertaken as soon as a diagnosis is made. There is a direct correlation between immediate medical treatment and a positive outcome. Waiting even a small amount of time to seek medical treatment can be a fatal mistake and shouldn't be considered. Likewise, those who are exhibiting potential symptoms of dengue hemorrhagic fever should be seen by a medical expert immediately for diagnosis. Identification Management of dengue hemorrhagic fever really only takes the form of symptomatic treatment. Because dengue is caused by a virus, antibiotics and other such medications aren't effective in fighting it. There is currently no real treatment that directly affects the virus itself. Instead, treatment generally focuses on relieving the symptoms that are caused by the infection. As with other viral infections, such as influenza, bed rest and increased fluid intake are crucial. Blood transfusions can also be necessary because of the increased bleeding that is often found in dengue patients. During the first 5 to 7 days, the infection is at its worst, and it is very important that the patient's vital signs be constantly monitored and that the patient remain hospitalized. Considerations Of course, the most effective way of managing dengue hemorrhagic fever is to prevent it in the first place. There is no viable dengue fever vaccine at the present time, but a great deal of work is being done toward that end, and vaccines are in development. Dengue is spread, like malaria, by mosquitoes. Proper mosquito management in tropical climates, particularly in urban areas, is one method of preventing dengue outbreaks from occurring in the first place. Warning Some medications should be absolutely avoided by those who have dengue hemorrhagic fever or who may be infected with it. The main drugs to avoid are NSAIDs (non-steroidal anti-inflammatory drugs) and aspirin, along with any other medication that has a thinning effect on the blood or can cause increased risk of bleeding. Bleeding is already a huge risk factor for those suffering from dengue fever, and medications that exacerbate this risk should be avoided at all costs. Nursing Management Nursing management of dengue fever is non-specific and supportive, consisting of pain relief and oral and/or intravenous administration of fluids. Dengue patient care requires vigilant medical monitoring for warning signs of the potentially fatal vascular permeability of dengue hemorrhagic fever (DHF) and life-threatening circulatory failure defining dengue shock syndrome (DSS). Significance Dengue fever results from infection by a flavivirus with four distinct serotypes (DEN-1, DEN-2, DEN-3, DEN-4). Aedis aegypti mosquitoes transmit dengue virus between humans. Dengue fever is endemic in much of Africa, Southeast Asia, and various tropical regions worldwide. Aedes albopictus mosquitoes are implicated to a lesser extent with dengue transmission in the Americas. Dengue fever impacts 50 to 100 million people annually with several hundred thousand patients progressing to more severe cases of dengue hemorrhagic fever (DHF). Dengue hemorrhagic fever causes fatality in 5 percent of patients with this disease manifestation. Effects Dengue virus causes an acute condition of increased vascular permeability and plasma leakage. Supporting the patient through this vascular crisis by proper hydration management leads to resolution. Time Frame Dengue fever exhibits seasonal activity, with epidemics occurring during rainy seasons conducive to mosquito breeding. In endemic regions, dengue should be the presumed initial diagnosis when treating a patient with flu-like symptoms during the rainy season. Dengue virus incubates three to fourteen days, after which dengue fever patients present with fever as high as 40 to 41 degrees C, myalgia, post-orbital pain, headache, appetite loss, nausea, vomiting, and petechial or maculopapular rash. Infants may present with undifferentiated febrile illness. Acute fever generally lasts three to seven days, often with a saddleback appearance where fever briefly remits and subsequently returns. Severe forms of dengue fever usually develop three to six days after disease onset. Identification Differential diagnosis includes other viral hemorrhagic fevers, malaria, measles, meningococcemia, leptospirosis, bacterial sepsis, typhoid fever, measles, rickettsial infections, rubella and influenza. Screenings include blood pressure, hydration status, tourniquet test, liver function, albumin level, pleural effusion index, CBC, and urology. Thirty percent of patients will present with hemorrhagic symptoms manifesting primarily as skin manifestations such a petechiae, echymoses, and purpura. Severe cases may also exhibit bleeding from the nose, gums, intestines, or an appearance of heavy menstruation. Urinalysis may indicate microhematuria. Confirmation of infection with dengue virus by tissue culture or serology does not yield timely results for clinical decisions. Therefore, diagnosis relies on empirical clinical evidence. Treatment for dengue fever and more severe manifestations of dengue hemorrhagic fever and dengue hemorrhagic shock is non-specific and supportive, consisting of pain relief and oral and/or IV administration of fluids. Features Well-hydrated patients with no signs of increased vascular permeability may recover at home with instructions for follow-up if hemorrhagic symptoms appear. Patients exhibiting signs of hemorrhage or dehydration require clinical observation or hospitalization. Protect dengue fever patients' hospital beds with mosquito nets preventing further transmission. It is important to avoid use of aspirin and nonsteroidal anti-inflammatory drugs in pain management, as this will exacerbate hemorrhagic complications. Acetaminophen is preferable. Supervision of hydration forms the core of nursing management of dengue fever. Offer patients oral liquids regularly, give IV fluids with early signs of dehydration, and monitor urine output. Nurses also must monitor blood pressure and watch for signs of circulatory decompensation including a weak, rapid pulse, hypotension,and cold, clammy skin. World Health Organization dengue training materials provide the formula for calculating rehydration volume as twice that required for normal maintenance: 2 x (1500 mL + (20 x (weight in kg -- 20)) for patients over 40 kg. Proper nursing management of dengue fever requires collection of multiple blood draws; serial hematocrits until one to two after fever resolution allow detection of hemoconcentration. Use an acute phase blood sample (days 0 to 5) taken at time of presentation for viral isolation in mosquito cell culture. Use convalescent samples for serotyping by ELISA. Collect tissue samples from the lymph nodes, lungs, liver, kidneys and spleen in fatal cases for immunohistochemistry studies. Discharge requirements include two-day absence of fever, return of appetite, normal hematocrit and platelets above 50,000/mm^3. Patients recovering from shock should remain in observation at least three days after resolution of the circulatory crisis. Patients suffering respiratory distress from pleural effusion may need a longer hospitalization. Warning Nursing management of dengue fever also requires monitoring patients for signs of altered consciousness, confusion and other neurological implications. Watch for lethargy, seizures, nuchal rigidity, and paresis. Neurological involvement and intense, sustained abdominal pain with vomiting often signal development of more severe dengue hemorrhagic fever (DHF). Relief from fever and a sudden onset of hypothermia accompanied by restlessness and mental changes often precede onset of dengue hemorrhagic shock syndrome (DSS). Expert Insight Previous infection with dengue fever does not confer cross-immunity to other dengue virus serotypes. Coinfection with multiple strains in endemic regions may contribute to increased virulence. A history of dengue fever or infection with multiple strains place patients at higher risk for dengue hemorrhagic fever (DHF). Medical Management Base medical management of dengue hemorrhagic fever on empirical clinical findings; physicians rarely receive dengue infection confirmation through viral isolation or serology during acute the acute phase of infection. Differential diagnosis requires consideration of influenza, malaria, measles, rubella, leptospirosis, meningococcemia, typhoid fever, bacterial sepsis and other viral hemorrhagic fevers. Blood pressure may be elevated on exam due to dehydration and compromised vascular permeability. Signs of hemorrhage include petechiae and bleeding from various orifices (vaginal, nasal, oral, anal, aural). According to the Centers for Disease Control, you can perform a tourniquet test by inflating the blood pressure cuff "midway between systolic and diastolic pressure for 5 minutes." Twenty of more petechiae per square inch indicate a positive result. Patients may exhibit mildly to moderately elevated liver enzymes, specifically aspartame aminotransferase (AST), alanine aminotransferase (ALT) and gammaglutamyl transpeptidase (GGT). Bilirubin and alkaline phosphotase may also show elevations. Warning Dengue fever patients exhibiting neurological symptoms such as seizures, confusion and lowered consciousness are at higher risk for subsequent development of dengue hemorrhagic fever (DHF). Watch for signs of impending circulatory failure and shock in patients with dengue hemorrhagic fever (DHF). Danger signs include intense sustained abdominal pain, repeated vomiting, rapid onset of hypothermia following fever and altered mental status. Considerations In the medical management of a suspected dengue fever fatality, request collection of fresh tissue samples from the heart, liver, kidney, lungs, intestines, spleen, lymph nodes, brain and skin (from an area exhibiting petechiae) for use in viral isolation and immunohistochemistry. Samples fixed in formalin are not suitable for viral isolation. Expert Insight The four flavivirus strains (DEN-1, DEN-2, DEN-3, DEN-4) causing dengue fever do not confer cross-immunity. A prior history of dengue fever infection does not preclude a current case of dengue fever. Co-infection with multiple strains is a distinct possible in endemic regions. Infection or co-infection with hepatitis B or hepatitis C may also lead to similar liver function test results.
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