dengue case study1

University of Makati

College of NursingJ.P. Rizal Extension, West Rembo Makati City

A Case Study on

Dengue Hemorrhagic Fever

In partial fulfillment of the requirements in

Maternal and Child Nursing 2

Submitted to

Professor Kathlyn Elizabeth Santiago

Submitted by

Johnson BainganCatherine CalimlimJanice Pola Congzon

Ma. Theresa DimaculanganDean Fornea

Erlyn RegondonRonaldo Zamora

September 2008

A C K N O W L E D G M E N T

First of all, we would like to thank the Almighty God for the enlightenment

and strength He has bestowed on us in doing this case study.

We would like to acknowledge the following people:

To Ms. Kathleen Elizabeth Santiago for being one of our mentors;

To Mr. Edgar Clariz, for allowing us to review the medical records of our

patient; and

To our group, for the effort and a job well done!

TABLE OF CONTENTS

I INTRODUCTION............................................................................1

II OBJECTIVE....................................................................................4

III ANATOMY AND PHYSIOLOGY........................................................5

IV DENGUE AND DENGUE HEMORRHAGIC FEVER..........................10

V PATHOPHYSIOLOGY...................................................................16

VI COMPREHENSIVE HEALTH HISTORY...........................................27

VII PHYSICAL ASSESSMENT.............................................................29

VIII DIAGNOSTICS AND LABORATORY EXAMS..................................32

IX MEDICAL MANAGEMENT............................................................42

X COURSE IN THE WARD

…………………………………………………………… 44

XI DRUG ANALYSIS.........................................................................46

XII NURSING CARE PLAN.................................................................49

XIII HEALTH TEACHING.....................................................................58

I. INTRODUCTION

Dengue infection is one of the most common mosquito borne viral diseases of

public health significance. It has been identified as a clinical entity since

1780. Dengue is found in tropical and sub-tropical regions around the world,

predominantly in urban and semi-urban areas. Dengue hemorrhagic fever

(DHF), a potentially lethal complication, was first recognized in the 1950s

during the dengue epidemics in the Philippines and Thailand, but today DHF

affects most Asian countries and has become a leading cause of

hospitalization and death among children in several of them where in age

groups that are predominantly affected are the preschool and school age.

This is a case of a 3 year-old male with Dengue Hemorrhagic Fever Category

II. Patient X is a toddler, admitted into the hospital around 5:00 am carried

by his mother. He is crying, looks weak and was not able to sleep well prior

to his admission, having eyebags are evidence of his restlessness. His mother

had told to the nurse that his child had already vomited three times before he

was brought to the hospital.

Doctors have diagnosed Patient X with DHF II with accompanying acute

tonsilopharyngitis. The patient tonsils were reddened and slightly inflamed

due to his tonsilphayringitis with a high fever measuring 40.5 oC. Patient’s

breath sounds were clear and no signs of dehydration as evidence by good

skin turgor. Rashes were not present on either extremities or on his body

area.

To support the doctors diagnosis of Dengue, his Attending Physician ordered

complete blood count, platelet count, blood typing, stool examination and

urinalysis. At this time the patient was already on IVF as part of his fluid

replacement therapy since he had vomited three times before his admission

and this also serve as his initial treatment to his diagnosis.

Patient X temperature was closely monitored during his 6 day stay in the

hospital. His first 3 days was a period of high-fever, a classic symptom of

Dengue Fever in its Febrile stage. On his first day, the patient had a

convulsive state due to his elevated fever. Frequent tepid sponge bath were

given to him, two to four times in an eight hour shift, in conjunction with his

anti-pyretic drug medication to relieve him from his discomfort brought by his

high temperature. Anti-biotics was also part of his medication to treat his

tonsilopharyngitis. Within his first three day stay, patient is irritable most of

time, restless and crying. Patient X seldom ate the foods served to him. On

his fourth day, a significant drop in his temperature was noted, as low as 36.8 oC which is a sign that the patient is entering into the toxic stage of Dengue

Fever. This state of defervescence, is a period where the number of patient’s

platelet is at its lowest. It is at this time where his attending physician

ordered another Laboratory request for CBC and PC to check if Patient X’s

platelet count is below the normal range of 150,000 to 350,000/L, which is

referred to as thrombocytopenia. The laboratory request was done in

anticipation of a possible bleeding episode where blood transfusion or

platelet transfusion will be administered. Frank bleeding is a worst case

scenario for a patient suffering from DHF. Laboratory test results is not

indicative of platelet count below 20,000 /L which would place the patient a

candidate for hemorrhagic bleeding.

After the significant drop of the client’s temperature, Patient X temperature

were elevated again for eight hours, a normal phenomenon for a DHF patient

before entering into the convalescent stage. His fifth day up to his seventh

day stay in the pediatric ward was a period of recuperation. Patient X’s

Attending Physician noted the appearance of Herman’s rash on his sixth day,

which is an indication that the patient is fully recovering since a rash after the

period of toxic stage is common to a patient suffering from DHF.

The patient was discharged on the seventh day with a resolving Dengue

Hemorrhagic Fever as his final diagnosis.

DENGUE HEMORRHAGIC FEVER 2

Dengue is an important differential diagnosis of fever in children and adults

presenting to first-level health facilities in tropical Asia and Latin America.

Dengue is not included in the generic Integrated Management of Childhood

Illnesses (IMCI) algorithm, but due to its importance, it was incorporated in

several Asian and Latin American IMCI adaptations. Most of these adaptations

have not been tested for their performance.

Prior to and in parallel with IMCI, there have been guidelines develop, on the

management of dengue. The “Guidelines for Treatment of Dengue

Fever/Dengue Hemorrhagic Fever in Small Hospitals” develop by the WHO

Regional Office is widely used. There has been no previous summary of

existing dengue guidelines to explore their usefulness in the context of IMCI

and to identify questions for research.

Dengue cases have become a normal occurrence at this time of the year and

it is always safe to remind people continuously about the danger of this

disease. This case study aims to identify and determine the general health

problems and needs of the patient with an admitting diagnosis of dengue

hemorrhagic fever. This presentation also intends to help patient promote

health and medical understanding of such condition through the application

of nursing skills. Moreover, paper is also intended to provide a better

understanding of the disease process based on the patient’s health history

and as a reference for future nursing students.

DENGUE HEMORRHAGIC FEVER 3

II. OBJECTIVESGeneral objective

This case study aims to identify and determine the general health problems

and needs of the patient with an admitting diagnosis of dengue hemorrhagic

fever. This presentation also intends to help patient promote health and

medical understanding of such condition through the application of nursing

skills. This paper is also intended to provide a better understanding of the

disease process based on the patient’s health history and as a reference for

future nursing students.

Specific Objectives

To raise the level of awareness of patient and family on health

problems that they may encounter

To facilitate the patient and family in taking necessary actions to

solve and prevent the identified problems on her own

To trace the disease process as well as possible etiologies.

To render nursing care and information to patient through the

application of the nursing skills.

To create a nursing care plan for individualized care of the

patient.

DENGUE HEMORRHAGIC FEVER

III. ANATOMY AND PHYSIOLOGY

HEMATOLOGIC SYSTEM

The hematologic system consists of the blood and the sites where blood is

produced, including the bone marrow and the reticuloendothelial system

(RES). Blood is a specialized organ that differs from other organs in that it

exists in a fluid state. Blood iscomposed of plasma and various types of cells.

Plasma is the fluid portion of blood; it contains various proteins, such as

albumin, globulin, fibrinogen, and other factors necessary for clotting, as well

as electrolytes, waste products, and nutrients. About 55% of blood volume is

plasma.

BLOOD

The cellular component of blood

consists of three primary cell types :

RBCs (red blood cells or

erythrocytes), WBCs (white blood

cells or leukocytes), and platelets

(thrombocytes). These cellular

components of blood normally make

up 40% to 45% of the blood volume.

Because most blood cells have a

short life span, the need for the body

to replenish its supply of cells is

continuous; this process is termed

hematopoiesis. The primary site for

hematopoiesis is the bone marrow.

During embryonic development and

in other conditions, the liver and spleen may also be involved. Under normal

conditions, the adult bone marrow produces about 175 billion RBCs, 70 billion

neutrophils (mature form of a WBC), and 175 billion platelets each day. When


the body needs more blood cells, as in infection (when WBCs are needed to

fight the invading pathogen) or in bleeding (when more RBCs are required),

the marrow increases its production of the cells required. Thus, under normal

conditions, the marrow responds to increased demand and releases adequate

numbers of cells into the circulation.

The volume of blood in humans is approximately 7% to 10% of the normal

body weight and amounts to 5 to 6 L. Circulating through the vascular system

and serving as a link between body organs, the blood carries oxygen

absorbed from the lungs and nutrients absorbed from the gastrointestinal

tract to the body cells for cellular metabolism. Blood also carries waste

products produced by cellular metabolism to the lungs, skin, liver, and

kidneys, where they are transformed and eliminated from the body. Blood

also carries hormones, antibodies, and other substances to their sites of

action or use.

Blood is made up of plasma (fluid component) and formed elements (cellular

component). Plasma consists of about 90% water and 10% solutes

(electrolytes, albumin, globulins, and clotting factors). The formed elements

include erythrocytes (red blood cells [RBCs]), leukocytes (white blood cells

[WBCs]), and platelets (PLTs).

To function, blood must remain in its

normally fluid state. Because blood

is fluid, the danger always exists that

trauma can lead to loss of blood

from the vascular system. To

prevent this, an intricate clotting

mechanism is activated when

necessary to seal any leak in the

blood vessels. Excessive clotting is

equally dangerous, because it can

obstruct blood flow to vital tissues.

To prevent this, the body has a fibrinolytic mechanism that eventually

dissolves clots (thrombi) formed within blood vessels. The balance between


these two systems, clot (thrombus) formation and clot (thrombus) dissolution

or fibrinolysis, is called hemostasis.

BONE MARROW

The bone marrow is the site of hematopoiesis, or blood cell formation. In a

child all skeletal bones are involved, but as the child ages marrow activity

decreases. By adulthood, marrow activity is usually limited to the pelvis, ribs,

vertebrae, and sternum. Marrow is one of the largest organs of the body,

making up 4% to 5% of total body weight. It consists of islands of cellular

components (red marrow) separated by fat (yellow marrow). As the adult

ages, the proportion of active marrow is gradually replaced by fat; however,

in the healthy person, the fat can again be replaced by active marrow when

more blood cell production is required. In

adults with disease that causes marrow destruction, fibrosis, or scarring, the

liver and spleen can also resume production of blood cells by a process

known as extramedullary hematopoiesis. The marrow is highly vascular.

Within it are primitive cells called stem cells. The stem cells have the ability

to self-replicate, thereby ensuring a continuous supply of stem cells

throughout the life cycle. When stimulated to do so, stem cells can begin a

process of differentiation into either myeloid or lymphoid stem cells. These

stem cells are committed to produce specific types of blood cells. Lymphoid

stem cells produce either T or B lymphocytes.Myeloid stem cells differentiate

into three broad cell types: RBCs,WBCs, and platelets. Thus, with the

exception of lymphocytes, all blood cells are derived from the myeloid stem

cell. A defect in the myeloid stem cell can cause problems not only with WBC

production but also with RBC and platelet production. The entire process of

hematopoiesis is highly complex.

PLATELETS (THROMBOCYTES)

Platelets, or thrombocytes, are not actually cells. Rather, they are granular

fragments of giant cells in the bone marrow called megakaryocytes. Platelet


production in the marrow is regulated in part by the hormone

thrombopoietin, which stimulates the production and differentiation of

megakaryocytes from the myeloid stem cell. Platelets play an essential role

in the control of bleeding. They circulate freely in the blood in an inactive

state, where they nurture the endothelium of the blood vessels, maintaining

the integrity of the vessel. When vascular injury does occur, platelets collect

at the site and are activated. They adhere to the site of injury and to each

other, forming a platelet plug that temporarily stops bleeding. Substances

released from platelet granules activate coagulation factors in the blood

plasma and initiate the formation of a stable clot composed of fibrin, a

filamentous protein. Platelets have a normal life span of 7 to 10 days.

PLASMA AND PLASMA PROTEINS

After cellular elements are removed from blood, the remaining liquid portion

is called plasma. More than 90% of plasma is water. The remainder consists

primarily of plasma proteins, clotting factors (particularly fibrinogen), and

small amounts of other substances such as nutrients, enzymes, waste

products, and gases. If plasma is allowed to clot, the remaining fluid is called

serum. Serum has essentially the same composition as plasma, except that

fibrinogen and several clotting factors have been removed in the clotting

process. Plasma proteins consist primarily of albumin and globulins. The

globulins can be separated into three main fractions—alpha, beta, and

gamma—each of which consists of distinct proteins that have different

functions. Important proteins in the alpha and beta fractions are the transport

globulins and the clotting factors that are made in the liver. The transport

globulins carry various substances in bound form around the circulation. For

example, thyroid-binding globulin carries thyroxin, and transferrin carries

iron. The clotting factors, including fibrinogen, remain in an inactive form in

the blood plasma until activated by the clotting cascade. The gamma globulin

fraction refers to the immunoglobulins, or antibodies. These proteins are

produced by the well-differentiated lymphocytes and plasma cells. The actual

fractionation of the globulins can be seen on a specific laboratory test (serum

protein electrophoresis). Albumin is particularly important for the

maintenance of fluid balance within the vascular system. Capillary walls are


impermeable to albumin, so its presence in the plasma creates an osmotic

force that keeps fluid within the vascular space. Albumin, which is produced

by the liver, has the capacity to bind to several substances that are

transported in plasma (eg, certain medications, bilirubin, some hormones).

People with poor hepatic function may have low concentrations of albumin,

with a resultant decrease in osmotic pressure and the development of

edema.


IV. DENGUE and DENGUE HEMORRHAGIC FEVER

Overview

Dengue infection is one of the most common mosquito borne viral diseases of

public health significance. It has been identified as a clinical entity since

1780. Clinical descriptions of the Australian outbreak in 1897 reported that

30 children died. The clinical manifestations of dengue infection range from

asymptomatic infection to undifferentiated fever, an influenza-like symptom

known as dengue fever, and a severe, sometimes fatal disease characterized

by hemorrhage and shock known as dengue hemorrhagic fever (DHF). The

first and second epidemics of DHF occurred in Manila in 1954 and 1956,

followed by the third in Bangkok in 1958. Since then, DHF has spread

throughout tropical Asian countries and has expanded globally.

Dengue viruses, single stranded RNA viruses of the family Flaviviridae, are

the most common cause of arboviral disease in the world. They are found

virtually throughout the tropics and cause an estimated 50-100 million

illnesses annually, including 250,000 - 500,000 cases of dengue hemorrhagic

fever a severe manifestation of dengue and 24,000 deaths. More than two

fifths of the world's population (2.5billion) lives in areas potentially at risk for

dengue. Because travelers to endemic areas are also at risk, healthcare

providers should have an understanding of the spectrum of infection, how to

diagnose it, and what the appropriate treatment is.

Dengue infection is caused by any of four dengue virus serotypes. The clinical

manifestations range from asymptomatic infection to undifferentiated fever,

dengue fever and dengue hemorrhagic fever (DHF). DHF is characterized by

sustained high fever for 2–7 days; bleeding diathesis such as positive

tourniquet test, petechiae, epistaxis and hematemesis; thrombocytopenia

with platelet counts less than 100 x 109 L and plasma leakage due to

increased vascular permeability evidenced by hemoconcentration, pleural

effusion and ascites. Bleeding diathesis is caused by vasculopathy,

thrombocytopenia, platelet dysfunction and coagulopathy. The three stages

of clinical presentations are classified as febrile, toxic and convalescent. The


toxic stage, which lasts 24–48 hours, is the most critical period, with rapid

plasma leakage leading to circulatory disturbance. The severity of DHF varies

from mild (World Health Organization grades I and II), with minimal and

transient change in vital signs, to severe (World Health Organization grades

III and IV), with threatened shock (e.g. blood pressure 100/90 mmHg) or

profound shock. There is no specific treatment for DHF. Intensive supportive

care is the most important aspect of management. Early recognition of the

disease and careful monitoring for circulatory disturbance are essential.

Optimal fluid therapy to maintain the functions of the vital organs during the

critical period and effective control of bleeding episodes will lead to favorable

outcomes. Administration of recombinant activated factor VII is suggested

whenever massive bleeding does not respond to blood component therapy.

SOCIO-DEMOGRAPHIC PROFILE

Dengue is a mosquito-borne infection which in recent years has become a

major international public health concern. Dengue is found in tropical and

sub-tropical regions around the world, predominantly in urban and semi-

urban areas.

Dengue hemorrhagic fever (DHF), a potentially lethal complication, was first

recognized in the 1950s during the dengue epidemics in the Philippines and

Thailand, but today DHF affects most Asian countries and has become a

leading cause of hospitalization and death among children in several of them.

An outbreak of dengue fever occurred in Cebu City from August 1987 to

January 1988. A total of 752 cases were hospitalized; 269 records were

reviewed, 20 patients were interviewed, and 18 blood samples were

collected. The majority of the cases were from urban areas. Seventy percent

of the cases were aged 10 years and younger. Fifty-three percent were

classical dengue fever; 22% Grade I; 21% Grade II; and 7% Grade III. There

were three deaths; the case fatality ratio was 0.4%. Three of the 18 blood

samples grew dengue virus serotype 1.

There are four distinct, but closely related, viruses that cause dengue.

Recovery from infection by one provides lifelong immunity against that

serotype but confers only partial and transient protection against subsequent


infection by the other three. There is good evidence that sequential infection

increases the risk of more serious disease resulting in DHF.

Prevalence

The global prevalence of dengue has grown dramatically in recent decades.

The disease is now endemic in more than 100 countries in Africa, the

Americas, the Eastern Mediterranean, South-east Asia and the Western

Pacific. South-east Asia and the Western Pacific are most seriously affected.

Before 1970 only nine countries had experienced DHF epidemics, a number

that had increased more than four-fold by 1995.

Some 2500 million people -- two fifths of the world's population -- are now at

risk from dengue. WHO currently estimates there may be 50 million cases of

dengue infection worldwide every year.

In 2001 alone, there were more than 609 000 reported cases of dengue in the

Americas, of which 15 000 cases were DHF. This is greater than double the

number of dengue cases which were recorded in the same region in 1995.

Not only is the number of cases increasing as the disease is spreading to new

areas, but explosive outbreaks are occurring. In 2001, Brazil reported over

390 000 cases including more than 670 cases of DHF.

Some other statistics:

During epidemics of dengue, attack rates among susceptible are often 40 --

50%, but may reach 80 -- 90%.

An estimated 500 000 cases of DHF require hospitalization each year, of

whom a very large proportion are children. At least 2.5% of cases die,

although case fatality could be twice as high.

Without proper treatment, DHF case fatality rates can exceed 20%. With

modern intensive supportive therapy, such rates can be reduced to less than

1%.

The spread of dengue is attributed to expanding geographic distribution of

the four dengue viruses and of their mosquito vectors, the most important of

which is the predominantly urban species Aedes aegypti. A rapid rise in urban

populations is bringing ever greater numbers of people into contact with this

vector, especially in areas that are favorable for mosquito breeding, e.g.


where household water storage is common and where solid waste disposal

services are inadequate.

Clinical Presentation

Dengue fever is a severe, flu-like illness that affects infants, young children

and adults, but seldom causes death.

The clinical features of dengue fever vary according to the age of the patient.

Infants and young children may have a non-specific febrile illness with rash.

Older children and adults may have either a mild febrile syndrome or the

classical incapacitating disease with abrupt onset and high fever, severe

headache, pain behind the eyes, muscle and joint pains, and rash.

The three stages of clinical presentation are named febrile, toxic

(hemorrhagic stage) and convalescent. The patients initially develop an

abrupt onset of high fever (39–40 °C) with malaise, headache, nausea,

vomiting, myalgia and, sometimes, abdominal pain. During the acute febrile

stage, which lasts 2–7 daysb (from DOH it is within the first 4 days),

hemorrhagic manifestation is invariably present but usually mild. Petechial

hemorrhage on the skin is commonly found. Also, a positive tourniquet test is

frequently observed. Bleeding at the nose, gastrointestinal tract (manifested

by abdominal pain) and gums is relatively less common compared with

petechiae, but may be severe. Flushing which may be accompanied by

vomiting, conjuctival infection and epistaxis may be observed at a later

period. Recently, menorrhagia has been more prevalent because of the

increasing number of affected adolescents. However, hematuria is extremely

rare. Hepatomegaly is commonly found, and the liver is usually soft and

tender. Thrombocytopenia and rising hematocrit due to plasma leakage are

usually detectable before the onset of the subsequent toxic stage. An abrupt

fall to normal or subnormal levels of temperature, varying degrees of

circulatory disturbance will develop, known as the toxic stage, lasts 24–48

hours. Ultimately, the majority of patients have rapid uneventful recovery

without sequelae in the convalescent stage.


Dengue hemorrhagic fever is a potentially deadly complication that is

characterized by high fever, hemorrhagic phenomena--often with

enlargement of the liver--and in severe cases, circulatory failure. The illness

commonly begins with a sudden rise in temperature accompanied by facial

flush and other non-specific constitutional symptoms of dengue fever. The

fever usually continues for two to seven days and can be as high as 40-41°C,

possibly with febrile convulsions and hemorrhagic phenomena.

In moderate DHF cases, all signs and symptoms abate after the fever

subsides. In severe cases, the patient's condition may suddenly deteriorate

after a few days of fever; the temperature drops, followed by signs of

circulatory failure, and the patient may rapidly go into a critical state of shock

and die within 12-24 hours, or quickly recover following appropriate volume

replacement therapy.

Diagnostic Criteria

The clinical diagnosis of DHF is based on four major characteristic

manifestations:

(i) sustained high fever lasting 2–7 days;

(ii) hemorrhagic tendency such as a positive tourniquet test, petechiae or

epistaxis;

(iii) thrombocytopenia (platelet count less than 100 x 109 /L); and

(iv) evidence of plasma leakage manifested by hemoconcentration (an

increase in hematocrit greater than 20% above average for age, sex

and population), pleural effusion and ascites.

Close observation, serial hematocrit and daily platelet count monitoring are

suggested in order to accomplish the clinical diagnostic criteria. Pleural

effusion can be demonstrated by a chest X-ray in right lateral decubitus view

at 12–24 hours after defervescence. These applications may be problematic

in a busy pediatric practice in a dengue-endemic area. A study in Vietnam

suggested to use fever and hemoconcentration together with either bleeding

or thrombocytopenia as clinical criteria of DHF. However, some patients with

bleeding or anemia will not have a rising hematocrit. Therefore, the minimal

criteria should include fever and evidence of plasma leakage together with

either bleeding or thrombocytopenia. Further evaluation in a large


prospective series from other dengue-endemic regions is warranted. The

severity of DHF is categorized into four grades: grade I, without overt

bleeding but positive for tourniquet test; grade II, with clinical bleeding

diathesis such as petechiae, epistaxis and hematemesis; grade III, circulatory

failure manifested by a rapid and weak pulse with narrowing pulse pressure

( less than 20 mmHg) or hypotension, with the presence of cold clammy skin

and restlessness; and grade IV, profound shock in which pulse and blood

pressure are not detectable.


V. PATHOPYSIOLOGY

Etiologic agent

Dengue viruses’ type 1, 2, 3, & 4

Alternative Names

Hemorrhagic dengue; Dengue shock syndrome; Philippine hemorrhagic fever;

Thai hemorrhagic fever; Singapore hemorrhagic fever

Definition/Transmission

Dengue hemorrhagic fever is a severe, potentially deadly infection bite by

certain mosquitoes (Aedes aegypti ). Day biting female mosquito that breeds

in the household or standing clean water.

Dengue viruses are transmitted to humans through the bites of infective

female Aedes mosquitoes. Mosquitoes generally acquire the virus while

feeding on the blood of an infected person. After virus incubation for 8-10

days, an infected mosquito is capable, during probing and blood feeding, of

transmitting the virus, to susceptible individuals for the rest of its life.

Infected female mosquitoes may also transmit the virus to their offspring by

transovarial (via the eggs) transmission, but the role of this in sustaining

transmission of virus to humans has not yet been delineated.

Humans are the main amplifying host of the virus, although studies have

shown that in some parts of the world monkeys may become infected and

perhaps serve as a source of virus for uninfected mosquitoes. The virus

circulates in the blood of infected humans for two to seven days, at

approximately the same time as they have fever; Aedes mosquitoes may

acquire the virus when they feed on an individual during this period.

Incubation Period

Uncertain, Probably 6 days to one week.


Period of Communicability

Unknown. Presumed to be on the first week of illness when virus is still

present in the blood.

Susceptibility, Resistance and Occurence

All persons are susceptible. Both sexes are equally affected. Age groups

predominantly affected are the preschool and school age. Adults and infants

are not exempted. Peak age affected 5-9 years of age.

Occurrence is sporadic throughout the year. Epidemic usually occur during

the rainy season as June – November. Peak months are September and

October.

Susceptibility is universal. Acquired immunity may be temporary but usually

permanent.

Causes

Four different dengue viruses have been shown to cause dengue hemorrhagic

fever. This condition occurs when a person catches a different dengue virus

after being infected by another type sometime before. Prior immunity to a

different dengue virus type plays an important role in this severe disease.

Worldwide, more than 100 million cases of dengue fever occur every year. A

small number of these develop into dengue hemorrhagic fever. Most

infections in the United States are brought in from other countries. It is

possible for a traveler who has returned to the United States to pass the

infection to someone who has not traveled.

Risk factors for dengue hemorrhagic fever include having antibodies to

dengue virus from prior infection and being younger than 12, female, or

Caucasian.

Pathogenesis

The pathogenesis of DHF is poorly understood. DHF caused by primary or

secondary dengue infection is due to the occurrence of abnormal immune

response involving production of cytokines or chemokines, activation of T-

lymphocytes and disturbance of the hemostatic system. upon the second

infection with a heterotypic dengue virus, the subneutralizing concentration


of the cross-reacting antibody from the previous infection may opsonize the

virus and enhance its uptake and replication in the macrophage or

mononuclear cells. Secondary infection with a heterotypic dengue virus is

associated with increased risk of developing DHF in individuals who have

recovered from a primary dengue virus with a first serotype. The level of T-

cell activation in a secondary dengue infection is also enhanced, occurring as

a phenomenon known as original antigenic sin, and is undergoing

programmed cell death. Many denguespecific T-cells are of low affinity for the

infected virus and show higher affinity for other, probably previously

encountered serotypes. Profound T-cell activation and death during acute

dengue infection may suppress or delay viral elimination, leading to the

higher viral loads and increased immunopathology found in patients with DHF

Symptoms

Early symptoms of dengue hemorrhagic fever are similar to those of dengue

fever, but after several days the patient becomes irritable, restless, and

sweaty. These symptoms are followed by a shock-like state.

Bleeding may appear as pinpoint spots of blood on the skin (petechiae) and

larger patches of blood under the skin (ecchymoses). Bleeding may occur

from minor injuries. Shock may cause death. If the patient survives, recovery

begins after a one-day crisis period.

Early symptoms include the following:

Fever

Headache

Muscle aches

Joint aches

Malaise

Decreased appetite

Vomiting

Acute phase symptoms include the following:

Shock-like state

Sweaty (diaphoretic)

Cold, clammy extremities

Restlessness followed by:

o Worsening of earlier symptoms


o Petechiae

o Ecchymosis

o Generalized rash

The severity of DHF is categorized into four grades: grade I, without overt

bleeding but positive for tourniquet test; grade II, with clinical bleeding

diathesis such as petechiae, epistaxis and hematemesis; grade III, circulatory

failure manifested by a rapid and weak pulse with narrowing pulse pressure

( less than 20 mmHg) or hypotension, with the presence of cold clammy skin

and restlessness; and grade IV, profound shock in which pulse and blood

pressure are not detectable.

Category I Category II Category III Category IV

History or presence of fever 2-7 days duration, with a (+) tourniquet test or presence of skin flushing or petechial rash

Category I plus Presence of one or more Danger Signs (especially defervescence)RestlessnessChanges in sensoriumCold, clammy skinSudden onset of abdominal painDifficulty of breathingCircumoral cyanosisSeizuresSpontaneous bleeding (gum bleeding, epistaxis, rashes, petechiae)

Category II plus Circulatory failureCold clammy skinWeak thready pulseNarrow pulse pressure ( less than 20mm/Hg)HypotensionRestlessness

Category III plus profound shock with undetectable pulse and blood pressure

Evidence of plasma leakage

The plasma leakage is due to the increased vascular permeability induced by

several mediators such as C3a, C5a during the acute febrile stage and

prominent during the toxic stage. The evidence of plasma leakage includes

hemoconcentration, hypoproteinemia/hypoalbuminemia, pleural effusion,

ascites, threatened shock and profound shock. The rising hematocrit may not

be evidenced because of either severe bleeding or early intravenous fluid

replacement.


Bleeding tendency

The bleeding diathesis is caused by vasculopathy, thrombocytopenia, platelet

dysfunction and coagulopathy.

Vasculopathy

A positive tourniquet test indicating the increased capillary fragility is found

in the early febrile stage. It may be a direct effect of dengue virus as it

appears in the first few days of illness during the viremic phase.

Thrombocytopenia and platelet dysfunction.

Patients with DHF usually have platelet counts less than 100 x 109/L.

Thrombocytopenia is most prominent during the toxic stage. The

mechanisms of thrombocytopenia include decreased platelet production and

increased peripheral destruction. The increased peripheral destruction is

markedly prominent during 2 days before defervescence. The bone marrow

then revealed hypercellularity with an increase in the megakaryocyte,

erythroblast and myeloid precursors. Hemophagocytosis of young and

mature erythroid and myeloid cells, lymphocytes and platelets was observed

Subsequently, the number of platelets is rapidly increased in the

convalescent stage and reaches the normal level within 7–10 days after the

defervescence.

Platelet dysfunction as evidenced by the absence of adenosine diphosphate

(ADP) release was initially demonstrated in patients with DHF during the

convalescent stage. The subsequent study during the febrile and early

convalescent stages by Srichaikul et al. in 1989 also demonstrated the

impaired platelet aggregation response to ADP that returned to a normal

response 2–3 weeks later. An increase in plasma - thromboglobulin and

platelet factor 4, indicating increased platelet secretory activity, was

observed. The platelet dysfunction might be the result of exhaustion from

platelet activation triggered by immune complexes containing dengue

antigen.

Coagulopathy


During the acute febrile stage, mild prolongation of the prothrombin time and

partial thromboplastin time, as well as reduced fibrinogen levels, have been

demonstrated in several studies. Variable reductions in the activities of

several coagulation factors, including prothrombin, factors V, VII, VIII, IX and

X, antithrombin and antiplasmin, have been demonstrated. Fibrin

degradation product or D-dimer is slightly elevated. Low levels of

anticoagulant proteins C and S and antithrombin III were found to be

associated with increasing severity of shock, presumably due to plasma

leakage. Elevated levels of tissue factor, thrombomodulin and plasminogen

activator inhibitor-1 reflect endothelial, platelet and/or monocyte activation

and may be a secondary response to direct activation of fibrinolysis by the

dengue virus. The coagulation abnormality is well compensated for in the

majority of patients without circulatory collapse. Most of the patients have

serum aspartate transaminase (AST) and alanine transaminase (ALT) levels

three and twofold higher than normal, respectively. There is focal necrosis of

hepatic cells, swelling appearance of Councilman bodies and hyaline necrosis

of Kupffer cells. Proliferation of mononuclear leucocytes and less frequently

polymorphonuclear leucocytes occurs in the sinusoids and occasionally in the

portal areas.

Possible Complications:

Shock

Encephalopathy

Residual brain damage

Seizures

Liver damage


Diagnostic Procedure

Physical examination may reveal the following:

Low blood pressure

A weak, rapid pulse

Rash

Red eyes

Red throat

Swollen glands

Enlarged liver

(hepatomegaly)

Tests may include the following

Hematocrit

Platelet count

Electrolytes

Coagulation studies

Liver enzymes

Tourniquet test (capillary fragility test or Rumpel Leads test) a

presumptive test which is positive in the presence of more than 20

petechiae within an inch square, after 5 minutes of test.

Inflate BP cuff on upper arm to a point midway between the systolic

and diastolic pressure of 5 min

Release cuff and make an imaginary 1square inch just below the cuff,

at the antecubital fossa

Count the number of petechiae inside the box


X-ray of the chest (may demonstrate pleural effusion)

Serologic studies (demonstrate antibodies to Dengue viruses)

Serum studies from samples taken during acute illness and

convalescence (increase in titer to Dengue antigen)

Get baseline platelet count and hematocrit; repeat daily if platelet

count is <100,000/uL

Take serial platelet count and hematocrit 1-3x daily

Monitor vital signs and urine output

Request for blood typing, clotting time and bleeding time

If necessary, do chest x-ray to assess pleural effusion, ECG for

myocarditis, or ABGs for metabolic acidosis

Optional: prothrombin time, partial thromboplastin time, fibrinogen,

total protein, albumin, globulin

Medical Management

Management Protocol in DHF by Dept. of Health (strategies)

Case diagnosis, management, referral

Health education/Advocacy

Rapid response mosquito control

Research and project development

Integrated vector control

Surveillance

Training

Medical Treatment

Symptomatic and supportive relief

Rapid replacement of Fluids (most important treatment) like oresol

and IV

o Give oresol at 75ml/KBW in 4-6hrs then maintain patient at 1-2L/day; continue giving other types of home fluids.


o Start IVF using D5LRS or D5 0.9NaCl or plain LRS:

o Give IVF at 5-7ml/KBW/hr if there is hemoconcentration or signs of plasma leakage. Then reduce IVF rate to 3ml/KBW/hr if there is subsequent improvement. Discontinue IVF after 24-48hrs if child remains stable. Otherwise, IVF may be increased by 3-5ml increments up to 15ml/KBW/hr until there is improvement and as long as patient is not in shock or there is no significant blood loss.

o Give IVF at 10-20ml/KBW IV bolus in <20minutes if patient is in shock; Repeat dose if there is no immediate improvement. Give plasma, plasma substitutes or 5% albumin at 10-20ml/KBW as rapid bolus if hematocrit rises and shock is still present. Give oxygen. Once improvement occurs adjust IVF same as above

o Give fresh whole blood at 1-ml/KBW if there is significant blood loss or if hematocrit continues to fall despite fluid resuscitation. If there is frank, uncontrolled bleeding.

o Give platelets when platelet count is below 150,000/uL or if there is significant blood loss and platelet count is below 150,000/uL, or there is continuous bleeding and hematocrit remains normal.

o Use fresh frozen plasma or cryoprecipitate in DIC. Correct metabolic acidosis

o Give oresol to replace fluid as in moderate dehydration at 75ml/kg in 4-6 hours or up to 2-3L in adults. Continue ORS intake until patients condition improves.

Paracetamol (NO ASPIRIN), for headache give analgesic

Fresh whole blood transfusion is ordered if thrombocytopenia and

platelet declines

For nose bleeding, flex the neck to prevent aspiration. Keep an

elevated position of trunk and promote vasoconstriction in nasal

mucosa membrane through an ice bag over the forehead

For melena, ice bag over the abdomen.

Avoid unnecessary movement


Assist in the management of shock. Dorsal recumbent to

trendelenburg position. Dorsal recumbent position facilitates

circulation.

For shock, provide warmth through lightweight covers, (overheating

causes vasodilation which aggravates bleeding)

Monitor vital signs, especially temperature because the critical period

for early signs of shock is the transition from febrile to afebrile phase

Diet: Low fat, low fiber, non irritating, non carbonated, non acidic

food. Noodle soup may be given. No dark colored foods, which can be

mistaken as melena for a dark colored stool.

The following have no role in treatment/or have not been

assessed adequately: Vit. C, steroids, IVIg

Outlook (Prognosis)

With early and aggressive care, most patients recover from dengue

hemorrhagic fever. However, half of untreated patients who go into shock do

not survive


VI. COMPREHENSIVE HEALTH HISTORY

Patient X is 2 years and 9 months old a male toddler born and raised from

South Cotabato

Informant: Patient’s mother

Reliability: 100%

Patient: Patient X

Birthday: November 10, 2005

Nationality: Filipino

Address: 271B, 61D, PA. South Cotabato

Type of Admission: Direct from ER

Attending Physician: Dr. X

Final Diagnosis: Dengue Hemorrhagic Fever II

Ward: Pediatric Ward

Hx: This is a case of a 3 year-old male with DHF II

Chief complaint: Fever

HPI:

10 hours PTA - (+) high grade fever, vomiting for several hours


Patient History

Patient X is a toddler, admitted into the hospital around 5:00 am carried by

his mother.

He is born healthy, under normal spontaneous vaginal delivery without any

body-marks or observable congenital birth defects. He has completed his

immunization program for the following vaccines: BCG, DPT, OPV, MEASLES

and HEPA-B.

Patient X being the youngest of three 3 siblings, stays with her mother most

of time at home. This is his first time to contact a serious illness since his

birth. Most of the time he frequently catch common colds and slight to

moderate fever but not of a high grade fever. The night prior to his admission

to the hospital, patient X is feverish and it worsens in the wee hours of the

morning. Patient is irritable, crying and has vomited for about three times.


VII. PHYSICAL ASSESSMENT

CATEGORY FINDINGS

General Appearance The patient looks weak and with eyebags.

Vital Signs Temperature: 40.5

Respiration: 30 cpm

Pulse Rate: 110

Blood Pressure: 90/40

Skin Upon inspection, the patient was noted to have flushed skin color

Hair The patient’s natural hair color is black. Soft and shiny.

Head/skull Upon inspection the skull is symmetrically aligned. No signs of lesions.

Eyes Eyes and eyebrows are symmetrically aligned with equal distribution of hair on both eyebrows.

PERRLA

Ears The color of both ears is the same with the facial skin and is symmetrically aligned. No ear discharge is noted.

Nose The external nose is symmetric and straight same color as with the facial skin. There is no nasal flaring. No obstruction in both nasal cavities

Lips Appears to be a little bit dry but not bluish or cyanotic. No lesions, cracks or warts are present

Neck The patient can move his head freely, no nodules palpated in the cervical area

Thorax/Lung Normal respiration, symmetrical chest expansion, clear breath sounds, negative retraction.

Heart/Cardiovascular Normal cardiac rate, symmetrical peripheral pulse noted.

Abdomen Normal bowel sound. Soft non tender abdomen

Muscoloskeletal Motor @ 4/5 upper and lower extremities

Both appear to be symmetric

Mental Status Conscious and oriented


Head and Neck:

(-) Decreased hearing

(-) Ringing in ears

(-) Frequent ear infections

(-) Dizzy spells

(-) Failing vision

(-) Double vision

(-) Blurred vision

(-) Eye pain

(-) Repeated eye infections

(-) Recurrent nose bleeds

(-) Dental disease

(-) Sinus trouble

(-) Frequent sore throats

(-) Neck swelling

(-) Hay fever

Respiratory

(-) Hoarseness

(-) Persistent cough

(-) Blood in spit

(-) Shortness of breath

Cardiovascular

(-) Chest pain traveling down left arm

(-) Palpitations

(-) Irregular heart beat

(-) Swollen ankles

(-) Fainting spells

(-) Pain in legs when walking

Genitourinary

(-) Painful urination

(-) Blood in urine

(-) Frequent urination

(-) Night time urinary frequency

(-) Loss of control of urine

(-) Decrease in force of urine stream

(-) Sexual dysfunction


Endocrine

(-) Chronic fatigue

(-) Weight loss – recent

(-) Bruise easily

(-) Cold extremities

(-) Tremors (shaking of hands)

(-) Convulsions

(+) Muscle weakness

Neurological

(-) Numbness

(-) Tingling sensations

(+) Headaches

(-) Nervousness

(-) Memory Loss

(-) Moodiness

(-) Difficulty falling asleep

(-) Difficulty staying awake

(+) Increased irritability

Musculoskeletal

(-) Neck pain

(-) Joint pain

(-) Low back pain

(-) Foot pain

(-) Stiff joints

Skin

(-) Petechiae rashes

(-) Hives

Past Medical History:

(-) previous hospitalization / OR / accidents

(-) asthma / allergy


HEMATOLOGY RESULT

Day 1

Hemoglobin-13.6 M:(13.0-18.0 Cms%) RBC 4.7 M: (4.5-6.5x10 L)

F:(12.0-18.0 Cms%) F: (3.8-5.8x10 L)

C:(11.7-13-0 Cms%) C: (4.0-5.2x10 L)

Hematocrit- 0.41 M:(0.40-0.54 Vol%) WBC---4.7---(4.5-10X10 L)

F:(0.37-0.47 Vol%)

C:(0.32-0.42 Vol%)

Differential Count:

Segmenters-----0.80 (0.50-0.70) Blood Type O+

Lymphocytes---0.20 (0.20-0.40) Bleeding Time----(1-4mins)

Eosinophils------------(0.01-0.05) Clotting Time-----(2-5mins)

Basophils---------------( -0.01 E.S.R M:(0.10mm/hr)

Monocytes--------------( -0.03) F: (0.20mm/hr)

Platelet Count—138 -(150-350 L)

Malarial Smear:_________________________

Others:________________________________

_________________________________ ______________________

(Commanding Officer) (Medical Technologist)

_________________________________ ______________________

(Comanding Officer) (Medical Technologist)


The Complete Blood Count is a screening test, used to diagnose and manage

numerous diseases. Test results shows normal value for Lymphocytes.

Eosiniphils Basophils and Monocytes values were not included in the

laboratory result, a marked increased in WBC indicates a positive infection.

Neutrophils/Segmenters are elevated, suggestive of Bacterial infection.

Lymphocytes are responsible for immune responses. An elevation is present

in cases of viral infection, leukemia, cancer of the bone marrow, or radiation

therapy while a decreased lymphocyte level can indicate diseases that affect

the immune system. A significant decrease in lymphocyte value indicates

low immune response.

Hematocrit values are indicators of ratio of RBC in relation to blood volume.

This is best compared with Hemoglobin value since the two values are

indicative of RBC present in the blood. The oxygen-combining ability of the

blood is in direct proportion to the hemoglobin concentration, rather than the

numbers of red blood cells, because some cells contain more hemoglobin

than others. Hemoglobin also serves as an important pH buffer in the

extracellular fluid. Hemoglobin determination is used to screen for anemia, to

identify the severity of anemia, and to assist in evaluating the patient's

response to anemia therapy. While a patient with a platelet count of less than

20,000 is at high risk for spontaneous bleeding.


HEMATOLOGY RESULT

Day 4

Hemoglobin-14.3 M:(13.0-18.0 Cms%) RBC 5 M: (4.5-6.5x10 L)

F:(12.0-18.0 Cms%) F: (3.8-5.8x10 L)

C:(11.7-13-0 Cms%) C: (4.0-5.2x10 L)

Hematocrit- 0.43 M:(0.40-0.54 Vol%) WBC---8.2---(4.5-10X10 L)

F:(0.37-0.47 Vol%)

C:(0.32-0.42 Vol%)

Differential Count:

Segmenters-----0.36 (0.50-0.70) Blood Type O+

Lymphocytes---0.64 (0.20-0.40) Bleeding Time----(1-4mins)

Eosinophils------------(0.01-0.05) Clotting Time-----(2-5mins)

Basophils---------------( -0.01) E.S.R M:(0.10mm/hr)

Monocytes--------------( -0.03) F: (0.20mm/hr)

Platelet Count—190 -(150-350 L)

Malarial Smear:_________________________

Others:________________________________

_________________________________ ______________________

(Commanding Officer) (Medical Technologist)

_________________________________ ______________________

(Comanding Officer) (Medical Technologist)

A decrease in neutrophils is known as neutropenia. Although most bacterial

infections stimulate an increase in neutrophils, some bacterial infections such

as typhoid fever and brucelosis and many viral diseases, including hepatitis,

influenza, rubella, rubeola, and mumps, decrease the neutrophil count. An

overwhelming infection can also deplete the bone marrow of neutrophils and

produce neutropenia.


URINALYSIS RESULT

Day 1

Physical Appearance

Test Result Normal

Color Yellow Yellow

Transparency Slightly hazy Clear

Reaction PH 6.0 4.6 - 8.0

Specific Gravity 1.030 1.010 – 1.035

Sugar Negative Absent

Protein Negative Absent

Microscopic

Test Result Normal

Pus Cell 0-3 Absent

RBC 0-1 0-5

Epithelial Cells Occasional

Protein Negative Absent

Crystal

Amorphous urates Positive

Amorphous Phosphate Blank


Urinalysis can disclose evidence of diseases, even some that have not caused

significant signs and symptoms. The color of urine is normally yellow, but if it

is reddish, this is indicative of presence of blood in the urine. Urine

transparency should be clear. Urine specific gravity measures the

concentration of particles in the urine. Increased urine specific gravity may

indicate dehydration, glycosuria and heart failure. Decreased urine specific

gravity may indicate excessive fluid intake and pyelonephritis. Urine normally

contains no glucose and abnormal results may indicate excessive diabetes

mellitus, renal glycosuria and increase Intra-Cranial Pressure. Protein is

normally not found the urine, specifically albumin. The most common cause

of protein in the urine is glomerular damage from renal disease, renal

distress, cardiac failure and febrile condition. Presence of pus cells can mean

there is kidney disease or an infection of the kidney, bladder or urinary tubes.

The presence of abnormal numbers of white cells in the urine is referred to as

pyuria. Normally there is no hemoglobin or RBC in the urine. RBC in the urine

may be due to many causes including kidney damage, tumors eroding the

urinary tract, stones, UTI and bleeding disorders.

The Appearance of urine, which is slightly turbid indicates infection. This is

even supported by the presence of pus in the urine. Presence of protein

indicates a renal distress. The increased specific gravity signifies dehydration

and glycosuria, supported by presence of glucose in the urine. Any

measurement below 1.007 to 1.010 indicates hydration and any

measurement above it indicates relative dehydration. Urine having a specific

gravity over 1.035 is either contaminated, contains very high levels of

glucose, or the patient may have recently received high density radiopaque

dyes intravenously for radiographic studies or low molecular weight dextran

solutions. Amorphous urates are observed in acidic urines and amorphous

phosphates are found in alkaline urine. The amorphous urates seen in urine

specimens are of little clinical value.


FECALYSIS

Day 3

Color: Yellow

Consistency: Soft

Fecalysis result is normal, no dark colored bowel that would indicate GI bleeding.

TYPHIDOT

Day 3

Test Result:

IgG : Positive

IgM : Negative

Interpretation of typhidot test should be based on the result of IgM. A positive IgM is

indicative of typoid fever. Typhidot test can be used as a valid tool in the diagnosis of

typhoid fever among Filipinos but whenever feasible, confirmation with blood cultures is

strongly encouraged especially with the appearance of drug resistant strains in the

community. A valid conclusion can be made from a single sample based on results of

IgM titer. Typhidot offers the advantage of speed, simplicity and early diagnosis.


SUMMARY OF LABORATORY RESULTS

Laboratory Exams Day 1 Day 3 Day 4 Normal ValuesHematology Resut Hemoglobin 13.6 14.3 13.0 - 18.0 Cms%Hematocrit 0.41 0.43 0.40 - 0.54 Vol%RBC 4.7 5 4.5 - 6.5x10 LWBC 4.7 8.2 4.5 - 5.2x10 LSegmenters 0.80 0.36 0.50 - 0.70Lymphocytes 0.20 0.64 0.20 - 0.40Platelet 138 190 150 - 350Urinalysis Physical Appearance Colory Yellow Yellow Transparency Slightly Hazy Clear Reaction pH 6.0 4.6 - 8.0 Specific Gravity 1.03 1.010 - 1.035 Sugar Negative Absent Protein Negative AbsentMicroscopic Pus Cell 0-3 Absent RBC 0-1 0 - 5 Epithelial Cells Occasional Protein Negative AbsentCrystal Amorphous urates Positive Amorphous Phosphate Blank Fecalysis Color Yellow Consistency Soft Typhidot IgG Positive IgM Negative


TPR SHEET

Day 1Hours Temperature Pulse

RateRespiratory

RateBlood

Pressure

8H 40.5 110 3012H 39.8 105 374H 37.5 102 358H 38.0 108 40

12H 38.8 108 304H 37.2 114 32

Day 2Hours Temperature Pulse Rate Respiratory

RateBlood

Pressure

8H 37.6 102 2412H 39.2 102 184H 39.3 122 248H 37.5 100 2712H 37.8 106 254H 38.1 108 27

Day 3Hours Temperature Pulse

RateRespiratory

RateBlood

Pressure8H 38.3 110 2812H 37.8 114 274H 38.1 116 268H 37.1 110 2712H 37.8 112 284H 38.8 116 29 90/40


Day 4Hours Temperature Pulse Rate Respiratory

Rate Blood Pressure

8H 38.2 118 4012H 38.2 118 354H 36.8 118 378H 39.4 126 4012H 38.3 114 344H 37.2 94 37

Day 5Hours Temperatur

ePulse Rate Respirator

y Rate Blood Pressure

8H 37.3 96 2312H 37.2 94 234H 36.6 82 228H 36.4 78 22

12H 36.0 70 264H 36.0 70 26

Day 6Hours Temperature Pulse Rate Blood

Pressure8H 37.3 94 28 90/50

12H 36.3 112 28 90/604H 36.4 100 288H 36.5 100 28 90/60

12H 36.0 102 264H 36.0 98 25 90/60


IV FLOW SHEET

Date

/Time

Started

Bot.

No.

Solution/

AMT/MEDS

ADDED/ RATE

IV SITE AMT

INFUSE

D

Date

/Time

Started

AMOUNT

ENDORSE

D

SIG

9/26 0745H

1 D5 0.3% NaCl 500cc x 50mggts/min

Right

Hand

500cc 2330H 30cc

9/26 2330H

2 D5IMB 500cc X 50mggts/min

Right Hand

500cc 0945H 280cc

9/26 1000H


Right Hand

500cc 9/27/06

1040H

180cc

9/28 1040H


Right Hand

500cc 9/28/06

2300H

20cc

9/28 2300H


Right Hand

500cc 9/29/06

2300H

220cc

9/29 2300H


Left Hand

500cc 9/30/06

0815H

80cc

9/30 0815H


Left Hand

500cc 10/01/06

0115H

110cc

10/01 0115H


Left Hand

500cc 10/01/06

0135H

10/01 1605H


Left Hand

500cc 10/01/06

0345H

10/01 1345H


Left Hand

500cc


IX. MEDICAL AND SURGICAL NURSING

Admission/Emergency Notes: Day 1

Assessment

Patient (+)Tonsillopharyngitis

Clear Breath Sounds

VS:

RR = 30 PR = 110

T = 40.5 BP = 90/40

Physicians Order

DIAGNOSTICS

CBC

QPC - done

Urinalysis - done

Stool Examination

THERAPEAUTICS

Admit to Pediaward

TPR every shift

DAT (Diet as Tolerated)

Monitor Vital Signs

Ampicillin 130 mg IV q8h ANST

Paracetamol 125mg/5ml 5ml q4h RTC

Paracetamol 300 mg/amp ½ ampule IV PRN

Ascorbic Acid 100mg/5ml 5ml OD

Refer to Dr. Soriano

@ 10:15 am

IVF d5 IMB 1000ml @ 50 ugtts, 24 hours

Increase ampicillin to 350 mg IV q6h ANST

@ 16:00 pm

For Bloodtyping

Physicians Order


Day 2

Continue Meds/IVF

Physicians Order

Day 3

Continue Meds/IVF

Request for Typhidot

Physicians Order

Day 4

Continue Meds/IVF

Request for CBC with QPC

VS q4h to include BP and record

Physicians Order

Day 5

IVF to follow, same

Physicians Order

Day 6

IVF to consume, D/C IV meds

MGH

Meds:

o Ascorbic acid 100ml/ 5ml 1 tsp OD

Diagnosis Dengue Hemorrhagic Fever II resolving


X. COURSE IN THE WARD

In day 1, a 3-year old male patient carried by his mother was admitted with a

chief complaint of fever. Ten hours prior to consultation, the patient had a

high grade fever and vomiting for several hours according to the mother.

The patient had a high grade fever of 40.5 0C and BP: 90/40. Diet as

tolerated was ordered. Upon assessment the patient is positive for

tonsillopharyngitis. . Anti-biotics was also part of his medication to treat his

tonsilopharyngitis. Ampicillin testing was done and had negative result. At

1000H, patient had a febrile seizure with temperature 41.80C, Paracetamol

was given. Stool examination was requested and the fecalysis result was

normal, the stool was soft, yellow colored stool. At 0100H, the patient

experienced chills with temperature of 38.80C. Paracetamol was given,

patient’s temperature went down to 370C.

In day 2, the patient is slightly febrile with temperature of 37.60C. The

mother was instructed to continue TSB and increase fluid intake.

In day 3, the patient is still febrile, Paracetamol via IV was given. Doctor

ordered for typhidot. The typhidot result were the following: IgG positive and

IgM negative. The patient is negative on typhoid fever.

In day 4, a significant drop in his temperature was noted, as low as 36.8 oC

which is a sign that the patient is entering into the toxic stage of Dengue

Fever. This state of defervescence, is a period where the number of patient’s

platelet is at its lowest. It is at this time where his attending physician

ordered another Laboratory request for CBC and PC to check if Patient X’s

platelet count is below the normal range of 150,000 to 350,000 /L, which is

referred to as thrombocytopenia. Hemoglobin, hematocrit, RBC WBC and

Platelet count are within normal limits. Segmenters are slightly decrease

with the value of 0.36 which is below the normal value of 0.50-0.70. After the

significant drop of the client’s temperature, Patient X temperature were

elevated again for eight hours, a normal phenomenon for a DHF patient


before entering into the convalescent stage. The patient had general rashes

with itchiness.

In day 5, the patient is afebrile and positive for Herman’s sign.

In day 6, the patient is afebrile and still positive for Herman’s sign.

Additional medication was ordered Ascorbic acid with dosage of 100mg/5mL

to be taken 1 tsp everyday. Diagnosis of Dengue Hemorrhagic Fever II was

resolved. The patient was discharged.


XI. Drug Study

BRAND NAME/GENERIC

CLASSIFICATION ACTION ROUTE&DOSAGE CONTRAINDICATIONS NURSING INTERVENTION

PARACETAMOLAcetaminophen

Antipyretic Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulating center.

Paracetamol 125mg/5ml PO – 5ml q4 RTCParacetamol 300mg/ampIV – ½ ampule IV PRN

- Contraindicated in patients hypersensitive to drug.· Use cautiously in patients with long term alcohol use because therapeutic doses cause hepatotoxicity in these patients.· Hematologic: hemolytic anemia, neutropenia, leukopenia, pancytopenia.· Hepatic: Jaundice· Metabolic: hypoglycemia· Skin: rash, urticaria.

- Use liquid form for children and patients who have difficulty swallowing.· In children, don’t exceed five doses in 24 hours.· Advise patient that drug is only for short term use and to consult the physician if giving to children for longer than 5 days or adults for longer than 10 days.· Advise patient or caregiver that many over the counter products contain acetaminophen; be aware of this when calculating total daily dose.· Warn patient that high doses or unsupervised long term use can cause liver damage.


BRAND NAME/GENERIC


AMPICILINAmpicillin

Anti-infective Antibiotic(Penicillin Family)

Inhibits cell wall synthesis during microorganism multiplication

Ampicillin: 130 mg IV q8h ANST

Children age 1 and older weighing less than 40kg (88lb): 300mg/kg daily IV in individual doses every 6 hours. Don’t exceed 4 g daily .

- Contraindicated in patients hypersensitive to drug or other penicillins

.

- Use cautiously in patients with other drug allergies because of possible cross sensitivity- Before giving drug, ask patient about allergic reactions to penicillin. However a negative history of penicillin allergy is no guarantee against a future allergic reaction- Obtain specimen for culture and sensitivity test before giving first dose. Therapy may begin pending results.-decrease dosage in patients with impaired renal function- Don’t use IM route in children-Monitor liver function test results during therapy- if large doses are given superinfection may occur


BRAND NAME/GENERIC


Ascorbic Acid Vitamins and Minerals

Stimulates collagen formation and tissue repair, involved in oxidation-reduction reactions

For extensive burns, delayed fracture or wound healing, severe febrile or chronic disease states

Oral liquid 100mg/5ml - 5ml OD

Contraindicated in patients with an allergy to tartrazine or sulfites. Large doses are contraindicated during pregnancy

Protect solution from light (IV) and refrigerate ampules

For patient receiving Vit. C, IM route may promote better utilization

Inform patient that Vit C is readily absorbed from citrus fruits, tomatoes, potatoes and leafy vegetables.


Assessment Nursing Diagnosis

Inference Goal Intervention Rationale Evaluation

SUBJECTIVE:“Kahapon pa siya inaapoy ng lagnat”, as verbalized by the patient’s mother.OBJECTIVE: Increase in body

temperature above normal range: 40.5 C

Profused Sweating

Dry lips and mucous membrane

Flushed skin Warm to touch

Hyperthermia related to direct effect of circulating endotoxins on the hypothalamus, altering temperature regulation.

Dengue Fever

Elevated WBC’s

Release of endotoxins, that cause disruption of hypothalamic set point

Increase in body temperature

After 8 hours of nursing intervention, the patient will demonstrate a temperature within the normal range, free of chills and associated complications.

Monitor patient temperature (degree and pattern) and note shaking chills or profused diaphoresis.

Monitor environmental temperature; limit or add bed linens as indicated.

Provide tepid sponge baths; avoid use of alcohol.

Administer antipyretics like acetylsalicylic acid (aspirin) and acetaminophen (Tylenol).

Provide cooling blanket.

Temperature of 38.9 - 41.1 C suggests acute infectious diseases process. Fever pattern may aid in diagnosis.

Room temperature or number of blankets should be alterd to maintain near normal temperature.

May help reduce fever. Use of alcohol may cause chills, actually elevating temperature.

Used to reduce fever by its central action on the hypothalamus.

Used to reduce fever usually greater than 40 C when seizures can occur.

Goal is met,after 8 hours of nursing intervention, the patient achieved a temperature within the normal range as evidenced by a decreased in body temperature from 40.5 C to 37 C. Patient was also free of chills and associated complications.




Subjective: “Ayaw kumain ng anak

ko ”, as verbalized by the patient’s mother.

Objective: Decreased tolerance

for activity Weakness Loss of muscle tone Weight upon

admission in kilogram: 13

Imbalanced Nutrition: less than body requirement related to loss of appetite secondary to dengue virus

Dengue Fever

Joint pain

Nausea, vomiting

Anorexia

Decreased appetite

After 3 days of nursing intervention, patient will demonstrate stable weight and will be free of signs of malnutrition. Patient or mother will demonstrate behaviors or lifestyle changes to maintain appropriate weight.

Independent:

Assess causative/ contributing factor:

Assess client's weight, age, strength, activity/rest level, and so forth Assess nutritional history, including food preferences

Observe and record patient’s food intake

Encourage client to choose food that are appealing to increase appetite

Avoid foods that causes intolerance, increase gastric motility that results in epigastric pain

Dependent:Establish a nutritional plan that meets individual needs:

Avoid foods that cause intolerances/

Provides comparative baseline

Identify deficiencies, suggests possible interventions

To monitor caloric intake or insufficient quality of food consumption

Toddlers eat a lot of food that are appealing to their taste

Foods such as gas-forming, spicy, too hot, too cold, caffeinated beverages can result to epigastric pain that will decrease appetite leading to weight loss

To enhance intake

To implement

Goal is met, after 3 days of nursing intervention, patient demonstrated stable weight and is free of signs of malnutrition. Patient’s mother also verbalized and demonstrated behaviors and lifestyle changes to maintain patient’s appropriate weight.


increase gastric motility

Consult dietitian/nutritional team as indicated

Provide nutritious food and diet modification as indicated.

Small frequent feeding with aspiration precaution

Promote pleasant, relaxing environment

Promote adequate/timely fluid intake

Weigh as often as possible and PRN

Note occurrence and report of constant sore throat.

Family support: Significant others should provide positive regard, love, and acknowledgement in guiding client with eating problem.

interdisciplinary team management

To prevent dehydration

To monitor effectiveness of efforts

Presence of inflamed throat may affect ability to eat/lose of appetite




Subjective:“Nanghihina at nanglalambot sya. Ni hindi nga nya kaya umupo para uminom ng gamot”, asverbalized by the patent’smother.

Objective: Decreased

tolerance for activity

Greater need for sleep and rest

Weakness and fatigue

Activity intolerance related to generalized weakness and reduced energy stores

Fever

Nausea and vomiting

Anorexia

Decreased appetite

Reduced energy stores

Muscle weakness and fatigue

After 8 hours of nursing intervention, the mother will report a measurable increase in activity tolerance

Assess patient’s ability to perform normal tasks noting complaints of weakness and fatigue

Provide quiet atmosphere, uninterrupted rest periods and maintain bed rest.

Implement energy-saving techniques like sitting, rather than standing, when administering oral medications or when providing tepid sponge baths.

Influences choice of intervention and needed assistance

Enhances rest to lower body’s oxygen requirements and reduces strain on the body

Maximizes available energy for other tasks.

Goal is met after 8 hours of nursing intervention, patient’s mother has reported a measurable increase in patient’s activity tolerance as evidenced by lesser complaints of fatigue and weakness and by increased tolerance in activities like sitting up to drink medicines




Objective:- Weakness andirritability.- Restlessness.

Laboratory Values:Platelet count: 130/ L

Hct : 0.41%Hgb: 13.6%

Risk for injury/bleedingrelated toaltered clottingfactor secondary to the coagulopathy effect of dengue virus

Dengue virus

Immune response involving production of cytokines and chemokines

activation of T-lymphocytes

vasculopathy, increase capillary fragility

disturbance of hemostatic system

thrombocytopenia and platelet dysfunction

prolongation of PT and PTT time

Severe bleeding

After 8 hours of nursing intervention, the motherof the client will learn through health teaching and demonstration the skills and practices in preventing injury to the patient that will cause him to bleed and to identify the signs of ongoing internal bleeding

Independent:- Assess for signs and symptoms of G.I bleeding. Check forsecretions. Observe color and consistencyof stools or vomitus.

- Observe for presence of petechiae, ecchymosis, bleeding from one more sites.

- Monitor pulse,Blood pressure.

- Note changes in mentation andlevel of consciousness.

- Avoid rectal temperature, be gentle with GI tube insertions.

- Encourage use of soft toothbrush, avoiding straining for stool, andforceful nose blowing.

- Use small needles forinjections. Apply pressure to venipuncture sites for longer than usual.

- Recommend avoidance of aspirin containing products.

Collaborative:

- The G.I tract (esophagus andrectum) is the most usual source of bleeding of its mucosal fragility.

- Sub-acute disseminatedIntravascular coagulation(DIC) may developsecondary to altered clotting factors.

- An increase inpulse with decreasedBlood pressure can indicate loss ofCirculating blood volume.

- Changes mayIndicate cerebralPerfusion secondary to,Hypoxemia

- Rectal andEsophageal vessels are most vulnerableto rupture.

- In the presenceof clotting factordisturbances,minimal trauma can cause mucosal bleeding.

- Minimizes damage to tissues, reducing risk for bleeding andhematoma.

- Prolongs coagulation, potentiating risk of hemorrhage.

Goal is met after 8 hours of nursing intervention, the motherof the client learned through health teaching and demonstration the skills and practices in preventing injury to the patient that will cause him to bleed as evidenced by providing soft toothbrush to the client and mother also identified the signs of ongoing internal bleeding as evidenced by frequent observation of the patients stool color




OBJECTIVE:

Rashes on chest area Mild scratching of patient is observed

Risk for impaired skin integrity related to the dengue virus as evidenced by mild scratching

Dengue virus infection

Immunoglobulin antibodies

attached to the surface of mast cells bind with an

antigen

Immune response system is activated

Histamine and chemoctactic substance are

released

Histamine causes permeability of blood vessels and peripheral

vasodilation

Resulting to non-specific febrile

illness with rash

After 8 hrs nursing intervention the patient will maintain optimal skin integrity as evidence by absences of skin breakdown

Independent:

Assess for rashes which may be present on other areas of body

Keep fingernails short

Apply cold compress or quick cold bath if not contraindicated

Maintain skin hygiene using mild soap and lukewarm water. Pat dry skin gently and thoroughly

Encourage adequate nutrition and hydration

Provide or advice

Hermans rash/sign usually appears on the upper and lower extremities about 1cm or less in size. Although typically located in extremities, unusual manifestation of rash may be generalized classic rash. Itchiness may be present at times

To prevent skin excoriation and secondary infection caused by scratching

To ease and give comfort to skin itchiness. Cold compress is vasoconstrictor which can reduce swelling

Skin hygiene needed to prevent secondary infection and avoid rubbing skin to prevent skin breakdown. Avoid harsh soaps that can dry and cause skin breakdown

To promote healthy skin

To prevent sweating and keep the skin dry.

Goal is met after 8 hours of nursing intervention, the clients skin integrity is not impairedas evidenced by the client’s intact skin that is free from breakdown and cuts




significant other to use light clothing material that is comfortable to the client

Use of baby powder after bathing or cleaning as indicated

Remove wet and wrinkled bed sheets promptly. Keep bed clothes dry, use non irritating materials and keep bed free of wrinkles, crumbs etc

Collaborative: Administer anti-itchiness as prescribe

Sweat can potentiate skin irritation and scratching

Moisture potentiates skin breakdown. Dry, crisp linen provides comfort to the client

To provide maximum relief from itchiness

To relieve client from itchiness


Assessment Nursing Diagnosis Inference Goal Intervention Rationale Evaluation

Objective:

Length of Stay: 5 days (ongoing)

Admitted at Pediatric Ward - sharing with other sick clients in a 15 bed capacity room

Risk for nosocomial infection related to prolonged hospital stay

Dengue virus

Prolonged hospitalization

(ongoing 5 days)

Exposure to pathogens

Risk for nosocomial infection

After an 8 hr of nursing intervention, the client’s significant others will verbalize understanding of desired preventive/precautionary skills in maintaining an aseptic environment to the client

-Observe for localized signs of infection at insertions sites of invasive lines, sutures, surgical incisions/wound

-Assess and document skin conditions around insertion of parenteral line

-Note signs and symptoms of sepsis, fever, chills, diaphoresis, altered level of conciousness, positive blood cultures

-Stress proper handwashing techniques by all caregivers

-Monitoring of visitor to prevent exposure of client

-Maintain sterile technique for invasive procedure such as IV line

-Review individual nutritional needs, and adequate rest

-Emphasize the necessity of taking antibiotics as directed

-Insertion sites of invasive lines, sutures, and surgical incisions are the most common site of infection

-Redness, swelling and pain are the signs of infection

-Early detection of infection will result in early diagnosis and treatment

-Proper handwashing lessen the transmission of pathogens

-Visitors can transmit pathogens to the client

-Infection can occur if the sterility of the procedure during IV insertion is compromised

-Adequate rest and nutrition helps maintain stability of the body therefore immune system is not compromised

-Completing the medicated antibiotics will treat the infection

Goal is met, after an 8 hr of nursing intervention, As evidenced by the client identifying/ practicing the appropriate behaviors and skills in maintaining an aseptic environment favorable to the client as evidenced by performing frequent handwashing before and after eating and attending to his child


XIII. HEALTH TEACHING

Medication

Intake of appropriate vitamin supplement to increase protection

mechanism of the immune system

Management

Management of such condition would be through hydration and doing

control measures to eliminate vector by promoting cleanliness in the

environment through proper disposal of rubber tires, changing water of

lower vases once a week, destruction of breeding places of mosquito

and residual spraying with insecticides.

Outpatient/Follow-up

Any odd signs such as fever, petechiae, recurrence of fever, etc. must

be immediately reported to the physician

There is no vaccine available to prevent dengue fever. Use personal

protection such as full-coverage clothing, netting, mosquito repellent

containing diethylmetatoluamide (DEET), and if possible, travel during

periods of minimal mosquito activity. Mosquito abatement programs

can also reduce the risk of infection.


References:

Suzanne C. Smeltzer Brenda G. Bare, Brunner & Suddarths’s Textbook

of Medical Surgical Nursing, 10th Edition, 2004

Frances Prescilla L. Cuevas, RN MAN, Public Health Nursing in the

Philippines, 10th Edition 2007

Catherine Paradiso, Lippincot’s Review Series – Pharmacology, 1998

Websites:

http://www.merck.com/mmpe/sec14/ch191/ch191b.html#sec14-ch191-

ch191b-2577

http://doh.gov.ph/

http://www.webmd.com/video/travel-dengue-fever


http://doh.gov.ph/

http://www.merck.com/mmpe/sec14/ch191/ch191b.html#sec14-ch191-ch191b-2577

http://www.merck.com/mmpe/sec14/ch191/ch191b.html#sec14-ch191-ch191b-2577