I.

Introduction
Dengue fever is a mosquito-borne illness that occurs in tropical and subtropical areas of the world. Mild dengue fever causes a
high fever and flu-like symptoms. The severe form of dengue fever, also called dengue hemorrhagic fever, can cause serious
bleeding, a sudden drop in blood pressure (shock) and death.

Symptoms:

 Many people experience no signs or symptoms of  Headache

a dengue infection.  Muscle, bone or joint pain
 When symptoms do occur, they may be mistaken  Nausea
for other illnesses — such as the flu — and usually  Vomiting
begin four to 10 days after you are bitten by an  Pain behind the eyes
infected mosquito.  Swollen glands
 Dengue fever causes a high fever — 104 F (40 C) —  Rash
and any of the following signs and symptoms:

Most people recover within a week or so. In some cases, symptoms worsen and can become life-threatening. This is called
severe dengue, dengue hemorrhagic fever or dengue shock syndrome. Severe dengue happens when your blood vessels become
damaged and leaky. And the number of clot-forming cells (platelets) in your bloodstream drops. This can lead to shock, internal
bleeding, organ failure and even death. Warning signs of severe dengue fever — which is a life-threatening emergency — can
develop quickly. The warning signs usually begin the first day or two after your fever goes away, and may include:

 Severe stomach pain

 Persistent vomiting
 Bleeding from your gums or nose
 Blood in your urine, stools or vomit
 Bleeding under the skin, which might look like bruising
 Difficult or rapid breathing
 Fatigue
 Irritability or restlessness

Dengue fever is caused by any one of four types of dengue viruses. You can't get dengue fever from being around an infected
person. Instead, dengue fever is spread through mosquito bites. The two types of mosquitoes that most often spread the
dengue viruses are common both in and around human lodgings. When a mosquito bites a person infected with a dengue virus,
the virus enters the mosquito. Then, when the infected mosquito bites another person, the virus enters that person's
bloodstream and causes an infection. After you've recovered from dengue fever, you have long-term immunity to the type of
virus that infected you — but not to the other three dengue fever virus types. This means you can be infected again in the future
by one of the other three virus types. Your risk of developing severe dengue fever increases if you get dengue fever a second,
third or fourth time.

Severe dengue fever can cause internal bleeding and organ damage. Blood pressure can drop to dangerous levels, causing shock.
In some cases, severe dengue fever can lead to death. Women who get dengue fever during pregnancy may be able to spread
the virus to the baby during childbirth. Additionally, babies of women who get dengue fever during pregnancy have a higher risk
of pre-term birth, low birth weight or fetal distress.

II. Objectives
 General Objectives:
At the end of this case scenario, student will be able to apply proper knowledge, skills and attitude in providing
care on Pedia patient with given illness.
 Knowledge:
Identify the etiology of dengue fever.
Give proper treatment and management options available for dengue fever.
Describe inter professional team strategies for improving care coordination and outcomes in pediatric patients
with dengue fever.
Evaluate the outcome criteria for the achievement and effectiveness of care.
Provide accurate head education to the mother or any family members of the patient with dengue fever.
 Skills:
Develop the skills in identifying the exact nursing diagnosis of the patient to provide adequate nursing care to
patients with diagnosed dengue fever. In order, help alleviate their suffering with proper health care and health
teaching.
 Implement proper nursing interventions.
 Attitude:
Establish the rapport with the patient with the client and members of the family.
Show outmost confidence in managing the client care.
Recognize client’s needs using holistic approach.

III. Nursing Health History

 Biographic data:
Name: Therese
Address: Not stated
Age: 7-years-old
Occupation: none
Source of information: Mother
Relationship to the patient: Daughter
Attending physician: Dr. Wong
Admitting Impression: Dengue fever
 Chief complaint:
3 days prior to admission the patient experienced on and off fever, headache, and muscle joint pain
 History of present illness:
When did the symptoms started?:
 3 days prior to admission
Whether the onset of symptoms was sudden or gradual:
 Gradual
How often the problem occurs:
 Not stated
Exact location of the distress:
 Head, and muscle joint
Character of the complaint (intensity or quality of symptoms):
 On and off fever, has a cold and clammy skin, and looks weak and pale
Factors that aggravate or alleviate the problem:
 Presence of stagnant water and unclean environment

 Past medical history:

Childhood immunization
 Family health history:
Mother: Not stated
Father: Not stated
 Personal and Social History:
Is an only child
Occupation of parents:
 Mother: Housewife
 Father: Private Company Driver
Home and Neighborhood Condition:
 Patient lives in a crowded area, with presence of stagnant water and unclean
environment

IV. Physical Examination

 Vital Signs:
o Blood pressure: 90/60 mmHg
o Temperature: 38.9°C
o Pulse rate: 115 bpm
o Respiratory rate 24 cycles per minute
o Weight: 25 kg
o Oxygen saturation: 95%
 Skin:
o Uniform color, except in the areas exposed to the sun, no edema nor lesions
 o Petechial rash in the upper left arm noted
o Cold, and clammy skin
o Good skin turgor
 Eyes:
o Eyebrows and eyelashes are evenly distributed, the eyelids have no discharge nor discoloration; pupils
are black in color skin, symmetrical, auricle aligned with outer cantus of eyes about 10◦ from vertical,
not tender; pinna recoils after it is folded able to hear sound in both ears.
 Hair:
o Evenly distributed hair, thick hair, no infection, nor presence dandruff
o Silky and resilient hair
o Head/scalp rounded, smooth skull contour, absences of nodules and masses; has symmetrical facial
features and movements
 Nose:
o Symmetric and straight no discharge or flaring, uniform color
o No tenderness nor lesions
 Lips/Mouth:
o Lips pink in color, soft, moist, smooth texture, ability to purse lips. Tongue in central position, moist,
and pink in color
 Abdomen:
o Uniform color, no evidence on enlarged liver or spleen. Audible bowel sounds, absence arterial bruits,
and absence at friction rubs, no tenderness

V. Symptoms Manifested
Patient manifested sign and symptoms:

o Off fever
o Headache
o Muscle joint pain for 3 days prior to admission
o Petechial rash appears on the left upper arm
o Cold and clammy skin
o She looks weak and pale

Other Signs and Symptoms in Dengue, which usually begin four to six days after infection and last for up to 10 days, may include:

o Sudden, high fever
o Severe headaches
o Pain behind the eyes
o Severe joint and muscle pain
o Fatigue
o Nausea
o Vomiting
o Skin rash, which appears two to five days after the onset of fever
o Mild bleeding (such a nose bleed, bleeding gums, or easy bruising)

VI. Pathophysiology

Predisposing Factor Precipitating Factor

1. Geographical Area- Tropical Environmental Condition- Crowded area
Island in the Pacific (Philippines) with presence of stagnant water and
2. Gender (Female) unclean environment.
3. Age
VII. Diagnostic and Laboratory
A. Chest X-ray AP View
 Look for pleural effusions and bronchopneumonia on a chest radiograph. Pleural effusion on the right side is
common. Patients with dengue shock syndrome often experience bilateral pleural effusions
B. CBC
 To check for a low platelet count, which is characteristic of the later stages of the disease, as well as a drop in
hemoglobin, hematocrit, and red blood cell (RBC) count (evidence of anemia) that occurs with extreme dengue
fever blood loss.
C. Platelet Count
 Determines the number of platelets in your sample
D. Dengue NS Antigen
 NS1 studies detect the dengue virus's non-structural protein NS1. During a dengue infection, this protein is
secreted into the bloodstream.
 NS1 tests for serum have been established. To detect dengue NS1 antigen, the majority of these tests use
synthetically labeled antibodies.
E. Elisa (Igm) IgG test

LABORATORY FINDINGS Normal Values Clinical Significance

Platelet Count 100 x10(9)/L 250,000 to 450,000 A low platelet count may also be called
μL thrombocytopenia.

Hg 12 g/L 12.0g/dl - 15.5g/dl Normal

Hct 40% 36% to 48% Normal

WBC 8 x10(9)/L 4.5 to 11.0 × 109/L Normal

 Used to diagnose new or previous dengue infections (if paired sera are collected within the correct time frame)

DIAGNOSTIC LABORATORY Clinical Significance

TESTS FINDINGS

Chest X-ray- Normal Lungs

 Dengue NS Positive A positive NS1 test result confirms dengue virus infection without providing serotype
Antigen information.

Elisa (Igm) IgG Negative Patients with negative IgM results before day 8 of illness and absent or negative NAAT or
Test-Igm NS1 results are considered unconfirmed cases. For these cases, a second sample should
be obtained after day 7 of symptoms for additional serologic testing.

IgG Negative Negative tests for IgM and/or IgG antibodies may 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.

On the 6th day:

LABORATORY FINDINGS

Platelet 200 x10(9)/L

Serology Test: Elisa (Igm) IgM Test Positive

IgGTest Positive

VIII. Medical and Surgical Management

 No treatment: No specific antiviral agents exist for dengue.
 Supportive care is advised: Patients should be advised to stay well hydrated and to avoid aspirin (acetylsalicylic
acid), aspirin-containing drugs, and other nonsteroidal anti-inflammatory drugs (such as ibuprofen) because of
their anticoagulant properties.
 Fever should be controlled with acetaminophen and tepid sponge baths.
 Febrile patients should avoid mosquito bites to reduce risk of further transmission.
 Rest as much as possible.

Severe dengue:

 For those who develop severe dengue, close observation and frequent monitoring in an intensive care unit may be
required.
 Severe dengue is a medical emergency. It requires immediate medical care at a clinic or hospital.
 Prophylactic platelet transfusions in dengue patients are not beneficial and may contribute to fluid overload.
 Administration of corticosteroids has no demonstrated benefit and is potentially harmful to patients; corticosteroids
should not be used except in the case of autoimmune-related complication (e.g., hemophagocytic lymphohistiocytosis,
immune thrombocytopenia purpura).
IX. Drug study

Drug Name Classification and Indications and Side Effects and Nursing Responsibilities
Mechanism of Action Contraindications Adverse Effects

Generic Name: Classification: Indication: Side Effects: -Assess patient’s fever: its
temperature and
Paracetamol Paracetamol is a This drug is used to -Allergic reaction to diaphoresis. -Assess allergic
(syrup) well-known treat mild to moderate paracetamol reactions: rash, urticaria; if
antipyretic and pain (from headaches, these occur, drug may have
Trade/Brand -Hives
Name: analgesic compound menstrual periods, -Difficulty breathing to be discontinued. -Check
opposed to a NSAID. toothaches, backaches, I&O ratio; decreasing
Calpol -Swelling of your face, output may indicate renal
osteoarthritis, or
Mechanism of lips, tongue, or throat. failure.
Dosage:125 mg cold/flu aches and
Action: Decreases
pains) and to reduce Adverse Effects: -Teach patient’s mother to
Route:Oral fever by inhibiting
fever. recognize signs of chronic
the effects of -Low fever with overdose: bleeding,
Frequency and pyrogens on the Contraindication: nausea, stomach pain, bruising, malaise, fever,
Timing: hypothalamus heat and loss of appetite and sore throat.
Contraindicated to
7.5 ml q 4 hrs. regulating centers
patients with: -Dark urine, clay - Paracetamol for children
(8-12-4-8-12-4) and by a
comes in different
PRN hypothalamic action • Hypersensitivity -Colored stools strengths. Parents should
leading to sweating take care they give their
and vasodilatation. • Intolerance to -Jaundice (yellowing
child the correct dose.
tartrazine, of the skin or eyes)
alcohol, table - For children who may
sugar, and refuse medicine off a
saccharin spoon try using a medicine
syringe to squirt liquid
• Allergy to slowly into the side of the
acetaminophen child’s mouth or use
soluble paracetamol mixed
with a drink.

X. Nursing Care Plan

Assessment Diagnosis Objective/Planning Intervention Rationale Evaluation

Subjective: Hypothermia Short-term goal: Independent: Goals have been
“Ga balik-balik related to After 2 hours of Provide tepid Heat loss by met as evidenced
lang permi ang inappropriate nursing sponge bath means of by maintenance
hilanat sang akon clotting factor as intervention, client evaporation and of core
bata” as evidenced by will be able to conduction. temperature
verbalized by the decrease in maintain core within normal
mother platelet count temperature within Promote surface Heat loss by range.
secondary to normal range as cooling by means means of
Objective: dengue evidenced by body of convection. radiation and
Temperature: hemorrhagic fever temperature is conduction.
38.9°C lowered to 37
PR: 115 bpm degrees Celsius Provide cool Heat loss by
BP: 90/60 mmHg environment. means of
Wt.: 25 mgs Long-term goal: convection.
Oxygen After 3 days of
Saturation: 95% nursing Maintain bed rest To reduce
intervention, and minimize metabolic
patient will no movement. demand of oxygen
longer show signs consumption.
and symptoms of
fever. Strictly monitor To know if the
temperature. patient’s
temperature went
down to the
normal value.

Discuss To prevent
importance of
 adequate fluid dehydration.
intake particularly
to the parents.

Increase fluid
intake. To lower the
temperature.
Dependent:
Paracetamol
syrup 7.5 ml 1 4 To alleviate the
hrs fever of the
patient

XI. Discharge Plan and Health Teachings

Diet:

 Encourage nutritious foods like vegetables, meat and fruits

 Instruct the family members to give the client protein rich foods such as meat, fish, eggs and nuts, vitamin K rich
foods such as green leafy vegetables, vit C rich foods (guava and tomatoes, and other citrus fruits), carbohydrates
rich food (breads and rice)

Medicine:

 Give acetaminophen in case the temperatures increases. It decreases pain and fever. It is available without a doctor's
order. Ask how much to take and how often to take it. Follow directions.
 Give oresol (Oral Rehydration Solution) to replace fluid in the body
 Remind to take the prescribed medicine, having a written reminder of the correct medication, time to take, and the
right frequency of the medicine on the way home to establish assurance of medication compliance.
 Don’t give aspirin and NSAID’s, they increase the risk of bleeding
 Any medicines that decrease platelet count platelet count should be should be avoided.

Exercise:

 Instruct to avoid excessive activities that may result to stress.

 Just advised to perform range of motions and repetitive body movements for promotion of optimum.

Treatment:

 Currently, no medications are available to treat dengue hemorrhagic fever.

 Increased oral fluid intake. You are at risk for dehydration if you have a fever, are vomiting, or have diarrhea. Ask
how much liquid to drink each day and which liquids are best for you. Normally, at least 8-10 glasses of water a
day.
 Bed rest
 Advise patient to maintain good and safe environment

Out-Patient Follow-Up Care:

• Instruct the family members to have a check-up or to consult physician once a while to monitor patient’s condition and
for detection of recurrences and other complications that may arise on to it.