Dengue Fever

HOLY NAME UNIVERSITY
THE PREMIER CATHOLIC UNIVERSITY IN THE PROVINCE OF BOHOL

College of Health Sciences – Nursing Department
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DENGUE FEVER
 Dengue fever is an infectious

disease carried by mosquitoes and
caused by any of four related
dengue viruses. This disease used
to be called "break-bone" fever
because it sometimes causes
severe joint and muscle pain that
feels like bones are breaking.
 The dengue virus is primarily
transmitted from person to person
through the bite of an infected
Aedes Aegypti mosquito (most
common vector)

Modes of Transmission
DENV can also be transmitted from an
infected woman to her fetus in utero or
infant during parturition. More research
is needed to determine perinatal
transmission rates and factors
associated with perinatal transmission.
Sources of DENV are:

•Saliva of infected Aedes spp. mosquito
•Blood or organs from an acutely
infected person

Modes of transmission include:

• Mosquito bite
• Perinatal transmission
• Blood transfusion
• Organ transplantation
• Needle stick injury or
Laboratory accident

Prevention:
There are many ways to prevent
dengue fever such as:
• Avoid crowded places. Stay away

from heavily populated residential
areas.
•Mosquito repellents. Use mosquito
repellents that are mild for the skin,
even indoors.
•Proper clothing. When outdoors,
wear long-sleeved shirts and long
pants tucked into socks.
•Mosquito-free environment. Make
sure window and door screens are
secure and free of holes or use
mosquito nets.
•Stagnant water. Empty or cover
bottles, cans, and any containers with
stagnant water as these can become
breeding places of mosquitoes.

Phases of Dengue Fever
After the incubation period, the illness

often begins abruptly with fever and will
follow three phases:
 Febrile phase
 Critical phase
 Recovery phase
Characteristics of the febrile phase:
 Typical duration of 0–7 days
 Biphasic fever possible
 Monitoring for defervescence (falling
of body temp to normal range) and
warning signs crucial to identify
progression into the critical phase.
Defervescence occurs between day
3 and day 8 of the illness.

Laboratory findings:
Febrile phase:
 Leukopenia
 Mild to
moderate thrombocytopenia
 Elevated aspartate
aminotransferase (AST)
 Elevated alanine aminotransferase
(ALT)
 Hyponatremia
Medical Complications during the
Febrile phase include the following:
 Dehydration
 Hyponatremia
 Febrile seizures in young children
 Neurologic disease manifestations,
including encephalitis and aseptic
meningitis

The critical phase typically begins

around the time of defervescence but
it might begin as early as the third day
after fever onset in patients who are
still febrile. This is the period when
those who develop severe disease
will become critically ill. However,
most dengue patients actually
improve during this phase and do not
develop severe disease.
Onset of the critical phase can also
be identified by the following:
 Rapid decline in platelet count with
a rise in hematocrit (HCT)
 The patient might develop
leukopenia up to 24 hours before
platelet drop is recognized
 Presence of warning signs for
severe disease

WARNING SIGNS!
 Severe abdominal pain/tenderness
 Persistent vomiting (at least 3
vomiting episodes within 24 hours)
 Vomiting with blood/ Mucosal bleed
 Drowsiness or irritability
 Dyspnea
 Swollen lymph nodes
 Diarrhea
 Clinical fluid accumulation, such
as ascites, pleural effusion
 Liver enlargement > 2 cm
 Lethargy or restlessness

Critical phase:
 Increase in Hematocrit or
hemoconcentration (blood
becomes concentrated)
 Moderate to severe
thrombocytopenia
 Leukopenia
 Transient increase in activated
partial-thromboplastin time
(aPTT) with decrease
in fibrinogen
Medical Complications during the
Critical phase include the following:
 Hypovolemic shock from
plasma leakage
 End organ impairment due to
prolonged shock
 Severe hemorrhage
 Encephalopathy

Recovery phase of Dengue

Recovery depends on the severity of
the illness and any treatments
prescribed in the febrile and critical
phases. Onset of the recovery phase
can be identified by the following:

 Patient improvement
 Gradual reabsorption of extravasated
fluid (such as from plasma leakage)
over 48–72 hours
 Increased diuresis (patient might wet
bed)
 Hemodynamic status stabilizes
 Patient can temporarily become
bradycardic (but hemodynamically
stable)

Clinical manifestations:
Recovery phase
 A second rash that might be
macular or erythematous with
small circular islands of normal,
unaffected skin. This
convalescent rash can be very
pruritic and desquamate.
 Severe fatigue
Recovery phase
 HCT stabilizes or is slightly lower

due to a dilutional (blood is no
longer concentrated) effect of
reabsorbed plasma (hemodilution)
 White blood count (WBC) begins
rising soon after defervescence
 Platelet count increases following
WBC recovery

Medical complications:
Recovery phase
Hypervolemia and acute pulmonary
edema can occur if intravenous fluid
(IVF) therapy has been excessive or
extended too long.
Organ impairment can result in the
event of prolonged
or refractory shock. This might
include ischemic hepatitis and hepatic
encephalopathy.
Nosocomial or hospital-acquired
infections, can occur, especially in
infants and elderly patients
Causes of Death
Severe dengue can result in death.
Causes include the following:
 Unrecognized dengue without
appropriate medical management
 Unrecognized or prolonged shock
 Unrecognized occult hemorrhage
 Fluid overload
 Nosocomial infections
 Liver failure
The revised/new (2009) WHO

guidelines emphasize the
importance of detecting clinically
significant plasma leakage
(due to increased vascular
permeability) early as a feature
that distinguishes severe from
non-severe dengue cases.

Dengue — With or
Without Warning Signs
Probable Dengue
Patient lives in or travelled to dengue-endemic
area. Patient also has fever and two or more of
the following clinical features:
• Nausea, vomiting (New)
• Rash
• Aches and pains (New: formerly, headache,
eye pain, myalgia, and arthralgia)
• Tourniquet test positive
• Leukopenia
• Any warning sign (New)
Warning Signs*
• Abdominal pain or tenderness
• Persistent vomiting
• Clinical fluid accumulation (ascites)
• Mucosal bleed
• Lethargy or restlessness
• Liver enlargement > 2 cm
• Laboratory finding of increasing HCT
concurrent with rapid decrease in platelet count

Severe Dengue
• Severe plasma leakage
• Severe hemorrhage
• Severe organ involvement
Patients are considered to have severe

dengue if they meet any of the following three
criteria.
1. Severe plasma leakage resulting in one
or both of the following:
•Shock
•Fluid accumulation with respiratory distress
2. Severe bleeding as evaluated by clinician
3. Severe organ involvement
•Hepatic (involving the liver): AST or ALT
level > 1000 U/L
•Neurologic (involving the central nervous
system): impaired consciousness
•Myocardial (involving the heart) and other
organs
Intravenous Fluids and The Dengue

Patient:
Normally, the ECF or
Extra Cellular Fluid is
divided into the fluid
surrounding the cell,
(interstitial fluid at 75%)
and plasma at 25%
In dengue patients,
there is plasma
leakage due to the
increased vascular
permeability.

Clinical Assessment
Tourniquet Test
The tourniquet test is part of the new WHO case
definition for dengue. The test is a marker of
capillary fragility and it can be used as a triage
tool to differentiate patients with acute
gastroenteritis, for example, from those with
dengue. Even if a tourniquet test was previously
done, it should be repeated if
 It was previously negative
 There is no bleeding manifestation
How to do a Tourniquet Test:
1. Take the patient's blood pressure and record
it, for example, 100/70 mmHg
2. Inflate the cuff to a point midway between
Systolic BP and Diastolic BP
and maintain for minutes. (100 + 70) ÷ 2
= 85 mmHg
3. Reduce and wait 2 minutes.
4. Count petechiae below antecubital fossa.
(See image below)
5. A positive test is 10 or more petechiae per 1
square inch.
Petechiae seen in patients with Dengue fever

Medical Management:
 Supportive measures
 Oral rehydration therapy
• Oral rehydration therapy is
recommended for patients with
moderate dehydration caused by
high fever and vomiting (ORS)
 Oral fluids
• Increase in oral fluids is also
helpful.
 Fluid resuscitation (using IVFs-
Colloids & Crystalloids)
• To prevent dehydration
(monitor the patient’s Intake & output
– urine output is a good indicator of
hydration ; urine must be clear yellow,
should not be dark yellow/orange )
 Blood Component Therapy
• Packed Red Blood Cells (PRBC)
• Fresh Frozen Plasma (FFP)
• Platelet Concentrate
 Oxygen Therapy
 Avoid aspirins
• Aspirin can thin the blood. Warn
patients to avoid aspirins and other
NSAIDs as they increase the risk for
hemorrhage.
 Inotropes – Dopamine, Dobutamine,
Epinephrine, Norepinephrine
Click here to watch a simple ex

planation on Dengue Fever:
https://www.youtube.com/watch?v=x6WZAigrkrE

Nursing
Management:
Nursing management of patients with DHF is
essential in achieving complete recovery.
Assessment should include:
 Evaluation of the patient’s heart rate,

temperature, and blood pressure (check
patient’s V/S)
 Evaluation of capillary refill, skin color and
pulse pressure.
 Assessment of evidence of bleeding in the skin
and other sites (e.g., gum & nose bleeding)
 Measurement and assessment of the urine
output.
Nursing
Interventions
Nursing interventions appropriate for a patient with
DHF include:
Blood pressure monitoring. Measure blood
pressure as indicated.
Monitoring pain. Note client report of pain in
specific areas, whether pain is increasing, diffused,
or localized.
Vascular access. Maintain patency of vascular
access (IV site) for fluid administration or blood
replacement as indicated.
Medication regimen. There must be a periodic
review of the medication regimen of the client to
identify medications that might exacerbate bleeding
problems.
Fluid replacement. Establish 24-hour fluid
replacement needs.
Managing nose bleeds. Elevate position of the
patient and apply ice bag to the bridge of the nose
and to the forehead.
Trendelenburg position. Place the patient in
Trendelenburg position to restore blood volume to
the head.

When is a Dengue Patient

Discharged from the Hospital?
Patients can be discharged from the hospital when all of the
following occur:
•No fever for 24–48 hours
•Improvement in clinical status
• General well being
• Appetite
• Hemodynamic status
• Adequate Urine output
• No respiratory distress
•Increasing trend of platelet count (usually preceded by
rising WBC)
•Stable Hematocrit with adequate oral intake while off IVFs
END OF PRESENTATION


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HOLY NAME UNIVERSITY

THE PREMIER CATHOLIC UNIVERSITY IN THE PROVINCE OF BOHOL

FAIR USE NOTICE AND

This PowerPoint presentation

Trailblazing Excellence in Educating Servant Leaders

 Dengue fever is an infectious

Trailblazing Excellence in Educating Servant Leaders

Sources of DENV are:

Trailblazing Excellence in Educating Servant Leaders

• Avoid crowded places. Stay away

Trailblazing Excellence in Educating Servant Leaders

Phases of Dengue Fever

After the incubation period, the illness

Trailblazing Excellence in Educating Servant Leaders

Trailblazing Excellence in Educating Servant Leaders

The critical phase typically begins

Trailblazing Excellence in Educating Servant Leaders

Trailblazing Excellence in Educating Servant Leaders

Trailblazing Excellence in Educating Servant Leaders

Recovery phase of Dengue

Trailblazing Excellence in Educating Servant Leaders

 HCT stabilizes or is slightly lower

Trailblazing Excellence in Educating Servant Leaders

The revised/new (2009) WHO

Trailblazing Excellence in Educating Servant Leaders

Trailblazing Excellence in Educating Servant Leaders

Patients are considered to have severe

Intravenous Fluids and The Dengue

Trailblazing Excellence in Educating Servant Leaders

Petechiae seen in patients with Dengue fever

Trailblazing Excellence in Educating Servant Leaders

Click here to watch a simple ex

Trailblazing Excellence in Educating Servant Leaders

Assessment should include:

 Evaluation of the patient’s heart rate,

Trailblazing Excellence in Educating Servant Leaders

When is a Dengue Patient

Trailblazing Excellence in Educating Servant Leaders

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