CASE

PRESENTATION

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
Introduction:
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: E.D.B
• Date : 7-21-09
• Time of Admission 10:45 AM
• Unit/Room: Pedia isolation
room
• Address: Norzagaray,
Baliuag, Bulacan
• Age: 8 y/o
• Gender: Female
• Status: N/A
• Religion: Roman Catholic
• Citizenship: Filipino
• Birth date: February 25, 2001
• Birthplace: OLSJDM
• Attending Physician:
• Final Diagnosis: DHF III
• Working Diagnosis: DFS I
• Chief Complaint: 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.

Lunch One (1) cup of rice, menudo and a

glass of water.

Dinner One (1) cup of rice, a slice of fried

fish a glass of water.
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 PR: 78 bpm

Temperature: 38.6 degrees celcius RR: 18 bpm

BODY PARTS TECHNIQUE USED NORMAL ACTUAL FINDINGS ANALYSIS

FINDINGS
A. SKIN Inspection, palpation Varies from light to Dark brown in color -Indicates impaired skin
deep brown, from complexion with some integrity.
ruddy pink to light presence of wounds and -Hyperthermia
pink, from yellow abrasions in the
overtones to olive, extremities of the client.
generally uniform No nodes or mass
skin temperature. elevation can be
palpated.. Hot to touch
and flushing skin.
B. HAIR Inspection Thick, silky, resilient, Thick and sticky with Improper personal
free from infestation, presence of some lice. hygiene.
evenly distributed
and covers the whole
scalp.
C. NAILS Inspection, Palpation Convex curvature Convex curvature smooth An indication of
smooth texture, texture, highly vascular improper hygiene.
highly vascular and and light pink to pale in
pink, prompt return color. Capillary refill
of pink less than 3 after 2-3 sec. Nails have
seconds. deposition of dirt in its
tips and sides.
D. NECK REGION Inspection, palpation Symmetrical and Symmetrical and Due to presence of
straight, no palpable straight, with palpable infection
lumps, and supple, lymph nodes
trachea is on midline
of neck, and spaces
are equal on both
sides.

E. LUNGS Auscultation Symmetrical chest Symmetrical chest Not normal. Crackles

expansion, clear expansion, Crackles sound is due to pleural
breath sounds. sound heard upon effusion.
auscultation. Dyspnea is
not observed.
F. HEART Auscultation Normal rate, regular No palpitation, no Normal
rhythm, no murmur. murmur

G. PERIPHERAL Palpation Symmetrical pulse Symmetrical pulse Normal

volume, full volume, full pulsation.
pulsation.

H. BREAST Inspection, Palpation Round shape, Symmetrical, with no Normal

slightly unequal in protuberance elevation.
size, generally
symmetrical, no
tenderness, masses,
nodules or nipple
discharge.
I. ABDOMEN Inspection, Uniform color, No scars seen upon Normal
Auscultation, rounded inspection. Uniform in
Percussion, symmetrical color, audible bowel
Palpation contour, audible sounds.
bowel sounds,
tenderness, liver
and bladder are not
palpable.

J. VAGINA Inspection No inflammation, No inflammation, Normal

swelling or swelling or discharge.
discharge.

K. UPPER AND Inspection Equal size on both Equal size on both Not normal
LOWER sides of the body, sides of the body. An Palpable lymph nodes
EXTREMITIES weakness on the ongoing IVF of D5LR indicates infection.
lower and upper hooked @ right arm Wounds indicates
extremities. regulated at 35 impaired skin
gtts/min. Lymph nodes integrity.
in the Axilla and groins
are palpable.
Noticeable presence of
wounds on the lower
right extremity and
both forearm.
1. SKULL Inspection, Palpation Proportional to the Proportional to the size Normal
size of the body, of the body with
round with prominence in the frontal
prominences in the and occipital area,
frontal and occipital symmetrical in all places.
area, symmetrical in
all places.
2. SCALP Inspection White, clean, free White, slightly oily, Improper hygiene..
from masses, lumps, without presence of
scars, and lesions, no masses, lumps, scars, and
areas of tenderness lesions but with presence
of lice.

3. FACE Inspection Oblong or round or Oblong shaped, Normal

square or heart symmetrical with no
shaped, symmetrical, involuntary muscle
facial expression that movements. No facial
is dependent on the grimace is observed.
mood or true feelings
and no involuntary
muscle movements.
4. EYES Inspection Parallel and evenly Parallel and evenly Normal
spaced symmetrical, spaced, pupils are bluish
non-protruding, pink gray in color, equal in
palpebral conjunctiva size.
and pupils black in
color, equal in size,
round and constricts
in response to light.
5. NOSE Inspection Midline symmetrical Midline symmetrical and Normal
and patent, no patent, no discharge.
discharge.

6. EARS Inspection Parallel symmetrical, Parallel symmetrical, Improper hygiene.

proportional to the proportional to the size
size of the head, of the head, bean-
bean-shaped, skin is shaped, skin is same
same color as the color as the surrounding
surrounding color, color, clean firm
clean firm cartilage. cartilage. With presence
of softened
cerumen.There is also a
presence of wound in the
pina of the right ear of
the client.
7. MOUTH Inspection Symmetrical, gums Symmetrical, gums Improper dental care.
pinkish in color, lips pinkish to dark in color,
margin is lips is also dark brown in
symmetrical, no color..margin is
lesion and symmetrical, no lesion
tenderness, without and tenderness, .She
involuntary have many dental
movement. cavities due to junk
foods.
HEMATOLOGY:
Date: July 21, 2009 Time: 6 Am
Blood Components Results Normal Values

Hemoglobin 142 120-150 g/L- F

140-170 g/L- M

Hematocrit 0.44 0.37-0.47 g/L - F

0.40-0.50 g/L - M

Platelet Count 80 150-350 microliter

WBC 13,400 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.
ANATOMY and PHYSIOLOGY:
BLOOD
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
 Erythropoiesis

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; 4-
11,000 per cubic mm
blood
• amoeboid motion
• chemotaxis
• leukocytosis
• leukopoiesis
• Colony stimulating
Factors and interleukins-
stimulates white blood
cell formation
Types of White Blood Cells
Platelets

• formed in the bone

marrow from cells called
megakaryocytes
• very small, 2-4 microns
in diameter
• approximately 250-
500,000 per cubic
millimeter
• essential for clotting of
damaged vasculature
• Thrombopoietin
stimulates the
production
 damage to endothelium of vessel

Platelet platelets adhesion

Plug
Formation
Platelets release reaction

platelets aggregation
 Pathophysiology Poor environmental sanitation

Mosquito bites a susceptible host

Virus multiply in the bloodstream

Creates multiple lesion in the blood stream Increased phagocytic

activity

Increase Excessive Increase fever

capillary consumption vascular
fragility of platelets permeability

Hemorrhagic Thrombocytopenia Leakage of plasma

manifestations

Pleural Effusion
Drug study
•Ranitidine
•Paracetamol
Medication Action Indication Contraindication Side Effects Nursing
Responsibilities

Decreases fever by Hypersensitivity • drowsiness • Assess patients

Generic Name: inhibiting the Treatment of fever • Nausea fever or pain:type
of pain, location ,
Paracetamol effects of pyrogens and pain. • Abdominal intensity,
on the hypothalamic pain duration,
Brand Name: heat regulating • Anemia temperature,
centers. • vomiting diaphoresis
• Assess allergic
Dosage: reactions:rash,
urticaria, if these
7-5 ml occur, drug may
have to be
Route: discontinued.
• Check input and
PO 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.
 Medication Action Indication Contraindication Side Effects Nursing
Responsibilities

Inhibits histamine Used in Hypersensitivity. • Bradycardia • Assess potential

Generic Name: at H2 receptor site management of History of acute • Headache for interactions
with other
Ranitidine in the gastric Various porphyria • Fatigue pharmaceutical
parietal cells, which Gastrointestinal • Dizzines agents patient
Brand Name: inhibits gastric acid disorders such as GI • Insomnia may be taking.
Zantac secretion. hemorrhage. • Depression • Use caution in
presence of renal
and hepatic
Dosage: impairment
• Do not take any
20 mg new medication
during therapy
Route: without
consulting a
TIV physician
• Take axactly as
Frequency: directed
q8 • 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 Nursing Nursing Planning Nursing Rationale Evaluation
diagnosis objective intervention
Subjective Cues: After 3 >Formulate >Perform TSB Promotes After 3 hours
“Mainit padin po Alterations hours of Independent Continuously heat loss of Nursing
in body through Intervention
ang pakiramdam Nursing plans to meet
temperatur conduction the clients
ko as verbalize by Intervention Your objective and temperature
the client.” e related to the clients in reducing evaporation. is decreased
Objective Cues: increase temperature clients’ >Remove Excessive into a normal
To promote
>Body temperature pyrogens will decrease temperature Clothes and covers surface range 37.3
of 38.6 degrees
in the into a normal >Gather cooling by degrees
bloodstrea evaporation celsius
celcius range(36.5- Materials
m 37.5 degrees Prevent
>Hot, flushed skin. needed in the >Promote
celsius) dehydration.
>diaphoresis Implementation Increase Fluid
Scientific
>Increased of the nursing intake
Explanati To reduce
WBC(13,400 μL) interventions. >Maintain bed rest. metabolic
on:
BP: 100/90 mmhg >Plan strategies demands
Body
PR: 78 bpm to educate >Provide Proper To promote
temperatur
Temperature: 38.6 Significant others Ventilation heat loss
e above
degrees celcius so that they can through
normal convection.
RR: 18bpm range be
helpful in your >Educate To reduce
their anxiety
Nursing Significant Others and get their
Intervention. Regarding Normal cooperation
Temperature and upon caring
Control measures for the client.
 Cues Nursing Nursing Planning Nursing Rationale Evaluation
diagnosis objective interventio
n
Subjective Cues: >Give For immediate
Antipyretics decrease in patients
Medication body temperature.
Objective Cues:
As ordered
BP: 100/90 mmhg
PR: 78 bpm
Temperature: 38.6
degrees celcius
RR: 18 bpm
 Cues Nursing Nursing objective Planning Nursing Rationale Evaluation
diagnosis intervention

Subjective Cues: After 3 days of >Plan Assessed Establishes After 3-days

Impaired skin Nursing interventio skin. Noted comparative of nursing
“Makati po ang integrity n that will color, turgor, baseline providing
intervention intervention,
mga sugat ko sa sa related to promote and opportunity for
mechanical the client will be wound sensation. timely the client was
braso at binti” as able to display able to
factors as healing in Described
verbalized by the evidence by improvement in a given and measured
intervention . Display
client disruption of span of wounds and
wound healing as Improvement
skin surface evidenced by: time. observed in wound
Objective Cues: >formulate changes
>presence of •Intact skin or healing as
Scientific ways on Demonstrat Maintaining
wounds in the minimized how to ed good skin clean, dry skin Evidenced
Explanation
lower right presence of teach hygiene, e.g., provides a barrier by:
Alteration of significant
extremity and both the wound.. wash to infection. •Minimized
forearm. •Absence of others in thoroughly Patting skin dry presence of
Epidermis proper and pat dry instead of rubbing
>pruritus because of Redness caring of wounds.
carefully. reduces risk of
>warm to touch external orerythema. the dermal trauma to •Several
wound surface. factors •Absence of wounds. fragile skin. wounds have
>with watery such as Purulent >Use Instructed Skin friction dried up.
discharge. shearing discharge. methods to family to caused by stiff or •Minimized
improve maintain rough clothes
force •Absence of skin Erythema
clean, dry leads to irritation
itchiness. integrity in clothes, •Minimized
of fragile skin and
an preferably increases risk for itchiness
accessible cotton fabric infection
and easy
way. (any T-shirt).
 Cues Nursing Nursing Plannin Nursing Rationale Evaluation
diagnosis objective g intervention

Subjective Cues: Emphasized Improved nutrition

importance of and hydration will
Adequate nutrition improve skin condition.
Objective Cues:
and fluid intake. Providing the family
BP: 100/90 mmhg
Demonstrated with alternative solution
PR: 78 bpm assists them in optimal
to the family
Temperature: 38.6 healing with less
members on how to
degrees celcius
RR: 18 bpm
make a guava expensive resources .
decoction to apply
to the wound as
Alternative
disinfectant. Long and rough nails
Instructed increase risk of skin
family to clip and damage.
file nails regularly.
Provided and Wound dressings
applied wound protect the wound and
the surrounding tissues.
dressings carefully.
DISCHARGE PLAN:
• 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.