Dengue Hemorrhagic Fever Presented by: Vernalin B. Terrado

Dengue Hemorrhagic Fever

General Objectives:
• The ultimate purpose of this study is to refresh the learned concepts about dengue hemorrhagic fever and to develop the understanding on the particular disease in accordance with further research and presentation based on the patients situation.

Specific Objectives:
This case presentation seeks to provide different information about the disease to be presented and about the client being considered with the following specific objectives: • Give a brief introduction about Dengue hemorrhagic fever together with its signs and symptoms. • Discuss the theoretical framework that is related to the client’s condition. • Present the client’s demographic data and health history with its Gordon’s pattern of functioning.

• Present the abnormal results of the Physical Assessment made on the client. • Present the different laboratory results or test done to the client with its interpretation. • Discuss the normal Anatomy and Physiology of the Blood. • Explain the Pathophysiology of Dengue Hemorrhagic Fever • Discuss the drugs prescribed to the client by a Drug Study. • Present an appropriate Nursing Care Plan for the most prioritized problem. • Give a Discharge Plan that the client may use upon discharge to the hospital

Dengue hemorrhagic fever is an acute febrile diseases found in tropics.It is a complication of Dengue fever with hemorrhages. It is characterized by abnormal vascular permeability, hypovolemia and abnormal blood clotting mechanism. The Dengue virus type 1,2,3,4, along with other arboviruse which are chikungunya, O’ nyong-nyong, west nile and flavi virus are classified as the causative agents. The vector responsible for the transmission of the virus is the domestic, day- biting mosquito known as the Aedes aegypti.The vector responsible for the transmission of the virus is the domestic, day-biting mosquito known as the Aedes aegypti.

Clinical manifestations according to its grade are persistent high fever, complains of pain, nausea and vomiting, and pathological vascular changes which is classified as Grade I, Grade II is persistence of signs and symptoms of Grade I with bleeding while Grade III has additional signs of circulatory failure and Grade IV with signs and symptoms of hypovolemic shock that can lead to death. Diagnostic test used to determine DHF are Rumpel leads test otherwise known as Tourniquet test and platelet count test that is shown in hematology examination.Treatment is mainly symptomatic and supportive.

Theoretical Framework:
Nightingale's core nursing theory has an environmental focus: It was her belief that the environment is an alterable medium that can be used to improve the conditions of Nature and encourage healing. Ventilation, clean air, clean water, control of noise, provision for light, and Adequate waste management are just a some of the elements She believed could be Monitored and improved when necessary.

Nightingale’s theory addresses the prevention of occurrences of Dengue Hemorrhagic Fever. In facilitating proper environmental sanitation we can achieve a surroundings with no presence of any vector that cause its transmission as they can no longer exist if the environment is not suited for their survival hence decreasing the morbidity rate of Dengue in our country. We should be knowledgeable on how to keep our surroundings free from any breeding sites that could serve as a reservoir for the mosquito. As a nurse we should teach our clients how to do proper water storage and environmental sanitation so as to prevent disease occurrence and recurrence.

Comprehensive History:
Biographic Data:

• • • •

Name: Date : Time of Admission Unit/Room:

• Address: • Age: • Gender: • Status:

E.D.B 7-21-09 10:45 AM Pedia isolation room Norzagaray, Baliuag, Bulacan 8 y/o Female N/A

• • • • • • • •

Religion: Citizenship: Birth date: Birthplace: Attending Physician: Final Diagnosis: Working Diagnosis: Chief Complaint:

Roman Catholic Filipino February 25, 2001 OLSJDM DHF III DFS I Abdominal pain with vomiting

Nursing History

Past Medical History
According to her mother the patient doesn’t experience any illness before that they treat of as an immediate concern aside from developing UTI when she was 5 years old. The patient only experienced having common cough and colds occasionally. She also experiences fever before and it was relieved by over the counter drugs and rest. Their family don’t seek consultation for regular health check up. She hasn’t been hospitalized and only seeks consultation to their Baranggay Health center whenever any health problem arises. She doesn’t also receive an immunization vaccine for measles.

History of Present Illness:
Five days prior to admission the client suffers from having a high fever with a temperature of 39. 4 degrees celcius, Paracetamol was given for relief. After three days the fever subsides and abdominal pain and vomiting of brownish colored vomitus takes place which prompted her hospitalization. Upon admission the child have experienced gum bleeding and have presence of petechiae over the face and lower extremities accompanied by fatigue and loss of appetite. Hematology examination shows low platelet count with a value of 80 mm3.
During the interview session she has a fever and experiences no bleeding at all. Her abdominal pain also ceases.

Family History:
According to the mother of the patient They only have history of hypertension on her mother side in their family while she doesn’t have any knowledge about the health history in the side of his husband. They claim to have suffered from no serious illness though they sometimes experiences common illnesses within the members of their family.

Activities of Daily Living
Gordon’s Functional Health Patterns

a. Health Perception and Health Management Pattern
The patient sees her pattern of health as normal as she suffered from no serious illnesses before. She manages her health by following her mothers instructions such as sleeping early and eating foods on regular basis. She also follows proper personal hygiene for her to become healthy.

b.Nutritional and Metabolic Pattern
The patient usually eats Vegetables because they have many of it planted in their backyard. She said that her favorite food is junk Foods especially chips and Salty foods. She is also fond of eating sweets such as chocolates and candies. She Usually drinks up to 6 glasses of water a day including other beverages. She is not taking any vitamin Supplements.

The following is her 24hour diet recall.
Breakfast One (1) cup of rice, fried egg with fried eggplant and a glass of chocolate drink. One (1) cup of rice, menudo and a glass of water. One (1) cup of rice, a slice of fried fish a glass of water.

Lunch Dinner

c. Elimination Pattern
She move her bowel twice a day with the usual color of light brown that occasionally change In accordance with her Choices of foods. She also urinates 4-5 times a day which has light yellow color.

d. Activity-Exercise Pattern
The usual activity pattern of the patient involves her activities of daily living, going to school and helping in light household chores. Her hobbies are watching TV and reading story books She spends most of her time playing outside with her cousins and friends.

e. Sleep-Rest Pattern
The client doesn’t have any difficulty in sleeping pattern. She sleeps at around 8 in the evening and wake up early. She doesn’t have the habit of sleeping at daytime. She usually drinks Milk before she goes to Sleep and she usually sleeps at about 10 hours daily.

f. Cognitive-Perceptual Pattern
The patient is able to read and write. She is currently in grade two in elementary education and portrays a sharp memory when asked about past experiences and significant others. She also has good eyesight and has a normal functioning for her senses and perception.

g. Self-Perception and Self Concept Pattern
She verbalizes Satisfaction with her abilities and talents. She Also describe herself as a Very jolly person though she is sad during the Interview because of her Current condition. With the help of her Mother she was able to answer most of my questions. She has good body posture and was able to maintain eye contact upon interview.

h. Role-Relationships Pattern:
She is the youngest among her siblings. She helps the other family members by doing and following little tasks whenever they ask her to do so. The patient has a good family relationship. She state that she is happy with them and they care and love her so much. The significant people in clients life is her mother.

i. Sexuality-Reproductive Pattern
This pattern is not asked because this is not applicable to the patient due to clients age.

j. Coping-Stress Pattern:
As a child she also deals with some of stressful events everyday. When she was in school her teacher helps her with her study and school works. She manage her problems with the help of the significant others. Her Status now being sick is one of The greatest stressor for the client and she was able to cope up because of their aid.

k.Values-Belief Pattern:
The client is a catholic and she usually goes to church every Sunday with her family. She state that being polite to them and Following elderly them is an Important value for her. She Usually prays at night before she goes to sleep. She believed That God is always with her And would never leave her no matter what happens..

V. Physical Assessment BP: 100/90 mmhg Temperature: 38.6 degrees celcius

PR: 78 bpm RR: 18 bpm

Varies from light toDark brown in color-Indicates impaired skin deep brown, from ruddycomplexion with someintegrity. pink to light pink, frompresence of wounds and-Hyperthermia yellow overtones toabrasions in the extremities olive, generally uniformof the client. No nodes or skin temperature. mass elevation can be palpated.. Hot to touch and flushing skin.



Thick, silky, resilient,Thick and sticky withImproper free from infestation,presence of some lice. hygiene. evenly distributed and covers the whole scalp.



Inspection, Palpation

Convex curvatureConvex curvature smoothAn indication of improper smooth texture, highlytexture, highly vascular andhygiene. vascular and pink,light pink to pale in color. prompt return of pinkCapillary refill after 2-3 sec. less than 3 seconds. Nails have deposition of dirt in its tips and sides.


Inspection, palpation

Symmetrical andSymmetrical and straight,Due to presence of straight, no palpablewith palpable lymph nodes infection lumps, and supple, trachea is on midline of neck, and spaces are equal on both sides.



Symmetrical chestSymmetrical chestNot normal. Crackles expansion, clear breathexpansion, Crackles soundsound is due to pleural sounds. heard upon auscultation.effusion. Dyspnea is not observed. Normal rate, regularNo palpitation, no murmur Normal rhythm, no murmur. Symmetrical pulseSymmetrical pulse volume,Normal volume, full pulsation. full pulsation.






Inspection, Palpation

Round shape, slightlySymmetrical, with noNormal unequal in size,protuberance elevation. generally symmetrical, no tenderness, masses, nodules or nipple discharge.


Inspection, Auscultation,Uniform color,No scars seen uponNormal Percussion, rounded symmetricalinspection. Uniform in Palpation contour, audible bowelcolor, audible bowel sounds, tenderness,sounds. liver and bladder are not palpable.



No inflammation,No inflammation, swellingNormal swelling or discharge. or discharge.



Equal size on bothEqual size on both sides ofNot normal sides of the body,the body. An ongoing IVFPalpable lymph nodes weakness on the lowerof D5LR hooked @ rightindicates infection. and upper extremities. arm regulated at 35Wounds indicates gtts/min. Lymph nodes inimpaired skin integrity. the Axilla and groins are palpable. Noticeable presence of wounds on the lower right extremity and both forearm.


Inspection, Palpation

Proportional to the sizeProportional to the size ofNormal of the body, round withthe body with prominence in prominences in thethe frontal and occipital frontal and occipitalarea, symmetrical in all area, symmetrical in allplaces. places. White, clean, free fromWhite, slightly oily, withoutImproper hygiene.. masses, lumps, scars,presence of masses, lumps, and lesions, no areas ofscars, and lesions but with tenderness presence of lice.





Oblong or round orOblong shaped, symmetricalNormal square or heart shaped,with no involuntary muscle symmetrical, facialmovements. No facial expression that isgrimace is observed. dependent on the mood or true feelings and no involuntary muscle movements. Parallel and evenlyParallel and evenly spaced,Normal spaced symmetrical,pupils are bluish gray in non-protruding, pinkcolor, equal in size. palpebral conjunctiva and pupils black in color, equal in size, round and constricts in response to light.





Midline symmetricalMidline symmetrical andNormal and patent, nopatent, no discharge. discharge.



Parallel symmetrical,Parallel symmetrical,Improper hygiene. proportional to the sizeproportional to the size of of the head, bean-the head, bean-shaped, skin shaped, skin is sameis same color as the color as the surroundingsurrounding color, clean color, clean firmfirm cartilage. With cartilage. presence of softened cerumen.There is also a presence of wound in the pina of the right ear of the client.



Symmetrical, gumsSymmetrical, gums pinkishImproper dental care. pinkish in color, lipsto dark in color, lips is also margin is symmetrical,dark brown in color..margin no lesion andis symmetrical, no lesion tenderness, withoutand tenderness, .She have involuntary movement. many dental cavities due to junk foods.

Date: July 21, 2009
Blood Components Hemoglobin Hematocrit Results 142 0.44

Time: 6 Am
Normal Values 120-150 g/L- F 140-170 g/L- M 0.37-0.47 g/L - F 0.40-0.50 g/L - M 150-350 microliter

Platelet Count




5,000-10,000 microliter

The result of hematology examination has a normal hemoglobin count as well as the hematocrit. On the other hand the platelet or the thrombocyte is way below the normal value which indicates thrombocytopenia while the leukocytes or the white blood cell increase which shows that there’s an infection present.

Blood- a connective tissue composed of a liquid extracellular matrix called blood plasma that dissolves and suspends various cells and cell fragments. 1 - Formed elements: • Red blood cells (or erythrocytes) • White blood cells (or leucocytes) • Platelets (or thrombocytes) 2 - Plasma = water + dissolved solutes

Characteristics of Blood:
• • • • • • • bright red dark red/purplish much more dense than pure water pH range from 7.35 to 7.45 slightly warmer than body temperature typical volume in an adult is 5 liters 8% of body weight

Major Functions of Blood:
• Distribution & Transport • Regulation (maintenance of homeostasis) • Protection

Formed elements
RBC • biconcave disk shape • a hemoglobin carrier • anucleate • No mitochondria • 120 lifespan • erythropoietin is the hormone that stimulates RBC production


RBC enters the circulation

Blood pass through the lungs And gas exchange occurs

Gas Exchange through tissues

RBC circulates for 120 days

WBC or Leukocytes:
• • • •

protection from microbes, parasites, toxins, cancer 1% of blood volume; 411,000 per cubic mm blood amoeboid motion chemotaxis

• •

leukopoiesis Colony stimulating Factors and interleukinsstimulates white blood cell formation

Types of White Blood Cells

• formed in the bone marrow from cells called megakaryocytes • very small, 2-4 microns in diameter • approximately 250500,000 per cubic millimeter • essential for clotting of damaged vasculature • Thrombopoietin stimulates the production

damage to endothelium of vessel

Platelet Plug Formation

platelets adhesion

Platelets release reaction

platelets aggregation


Poor environmental sanitation

Mosquito bites a susceptible host

Virus multiply in the bloodstream Increased phagocytic activity

Creates multiple lesion in the blood stream

Increase capillary fragility

Excessive consumption of platelets

Increase vascular permeability


Hemorrhagic manifestations


Leakage of plasma

Pleural Effusion

Drug study
•Ranitidine •Paracetamol





Side Effects

Nursing Responsibilities

Generic Name: Paracetamol Brand Name: Dosage:
7-5 ml

Decreases fever by Hypersensitivity inhibiting the Treatment of fever and effects of pyrogens pain. on the hypothalamic heat regulating centers.

• • • • •

• drowsiness Nausea Abdominal pain Anemia vomiting •

Route: PO

• •

Assess patients fever or pain:type of pain, location , intensity, duration, temperature, diaphoresis Assess allergic reactions:rash, urticaria, if these occur, drug may have to be discontinued. Check input and output ratio Inform th patient that urine may become dark brown as a result of phenacetin Teach patient to recognize signs of over dosage, bleeding, brising.





Side Effects

Nursing Responsibilities

Generic Name: Ranitidine Brand Name: Zantac Dosage: 20 mg Route: TIV Frequency: q8

Inhibits histamine at H2 receptor site in the gastric parietal cells, which inhibits gastric acid secretion.

Used in management of Various Gastrointestinal disorders such as GI hemorrhage.

Hypersensitivity. History of acute porphyria

• • • • • •

Bradycardia Headache Fatigue Dizzines Insomnia Depression

• •

• • •

Assess potential for interactions with other pharmaceutical agents patient may be taking. Use caution in presence of renal and hepatic impairment Do not take any new medication during therapy without consulting a physician Take axactly as directed Follow diet as physician recommends Report chest pain or irregular heartbeats, skin rash, CNS change; unusual persistent weakness or lethargy, yellowing of skin or eyes.

Nursing Care Plan
•Hyperthermia •Impaired Skin Integrity

Cues Subjective Cues: “Mainit padin po ang pakiramdam ko as verbalize by the client.” Objective Cues: >Body temperature of 38.6 degrees celcius >Hot, flushed skin. >diaphoresis >Increased WBC(13,400 μL) BP: 100/90 mmhg PR: 78 bpm Temperature: 38.6 degrees celcius RR: 18bpm

Nursing diagnosis

Nursing objective


Nursing intervention >Perform TSB Continuously

Rationale Promotes heat loss through conduction and evaporation. To promote surface cooling by evaporation Prevent dehydration. To reduce metabolic demands To promote heat loss through convection. To reduce their anxiety and get their cooperation upon caring for the client.

Evaluation After 3 hours of Nursing Intervention the clients temperature is decreased into a normal range 37.3 degrees celsius

>Formulate After 3 Alterations in Independent hours of body plans to meet Nursing temperature Intervention the Your objective related to clients in reducing increase temperature will clients’ pyrogens in decrease into a temperature the normal >Gather bloodstream range(36.5-37.5 Materials degrees celsius) needed in the Scientific Implementation Explanation: of the nursing Body interventions. temperature >Plan strategies above normal to educate range Significant others so that they can be helpful in your Nursing Intervention.

>Remove Excessive Clothes and covers

>Promote Increase Fluid intake >Maintain bed rest. >Provide Proper Ventilation

>Educate Significant Others Regarding Normal Temperature and Control measures


Nursing diagnosis Nursing objective


Nursing intervention >Give Antipyretics Medication As ordered



Subjective Cues: Objective Cues: BP: 100/90 mmhg PR: 78 bpm Temperature: 38.6 degrees celcius RR: 18 bpm

For immediate decrease in patients body temperature.


Nursing diagnosis

Nursing objective


Nursing intervention



Subjective Cues: “Makati po ang mga sugat ko sa sa braso at binti” as verbalized by the client Objective Cues: >presence of wounds in the lower right extremity and both forearm. >pruritus >warm to touch wound surface. >with watery discharge.

After 3 days of Nursing intervention the client will be able to display improvement in wound healing as evidenced by: Scientific •Intact skin or Explanation minimized Alteration of the presence of Epidermis wound.. because of •Absence of external factors Redness such as shearing orerythema. force •Absence of Purulent discharge. •Absence of itchiness. Impaired skin integrity related to mechanical factors as evidence by disruption of skin surface

Assessed skin. Establishes >Plan After 3-days intervention Noted color, comparative baseline of nursing that will turgor, and providing intervention, promote sensation. opportunity for the client was wound Described and timely intervention able to healing in a measured given span of wounds and Display time. observed Improvement >formulate changes ways on how Demonstrated Maintaining clean, in wound to teach dry skin provides a healing as good skin significant hygiene, e.g., barrier to infection. Evidenced others in wash thoroughly Patting skin dry by: proper caring and pat dry instead of rubbing •Minimized of the reduces risk of carefully. presence of wounds. dermal trauma to wounds. >Use fragile skin. methods to Instructed •Several Skin friction improve skin family to wounds have caused by stiff or integrity in an maintain clean, rough clothes leads dried up. accessible anddry clothes, to irritation of fragile •Minimized easy way. preferably skin and increases Erythema cotton fabric risk for infection •Minimized (any T-shirt). itchiness



Nursing diagnosis

Nursing objective

Planning Nursing intervention



Subjective Cues: Objective Cues: BP: 100/90 mmhg PR: 78 bpm Temperature: 38.6 degrees celcius RR: 18 bpm

Emphasized importance of Adequate nutrition and fluid intake. Demonstrated to the family members on how to make a guava decoction to apply to the wound as Alternative disinfectant. Instructed family to clip and file nails regularly. Provided and applied wound dressings carefully.

Improved nutrition and hydration will improve skin condition. Providing the family with alternative solution assists them in optimal healing with less expensive resources


Long and rough nails increase risk of skin damage. Wound dressings protect the wound and the surrounding tissues.

• • Medicine – Paracetamol PRN. -Don’t give aspirin and NSAIDs Exercise- Encourage patients to resume to her Activities of daily living -perform range of motions and repetitive body movements for promotion of optimum health. Therapy- Water Therapy -Promotion of proper personal hygiene. Health teachings- Change water in vases on alternate days. - cover water containers - used mosquito repellant lotions.. -avoid places with stagnant waters. Out patient follow up care- Instruct the family members to have a check-up after a week for detection of recurrences and other complications that may arise on to it.

• •

Diet- 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) Spiritual- Encourage the patient to pray together with the family to thank God for her wellness. Ask for more guidance and protection to prevent the recurrence of the disease among family members.

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