Chapter 1

INTRODUCTION

Dengue fever, also known as break-bone fever, is an infectious tropical disease caused by infection of the dengue virus. It is a mosquito borne of single positive stranded RNA virus from the family Flaviviridae. It refers to a benign form of disease with symptoms including fever, headache, muscle pain, joint pains, pain behind the eyes, and skin rash that is similar to measles. In some cases the disease develops into a life-threatening Dengue Hemorrhagic Fever (DHF). It is a severe and sometimes fatal manifestation of the dengue virus infection characterized by bleeding, low levels of blood platelets, and hypovolemic shock. Dengue is transmitted by mosquito Genus Aedes, principally female Aedes Egypti. Other Aedes species that transmit the disease include: Aedes Albopictus, Aedes Polynesiensis, and Aedes Scutellaris. There are four types of dengue fever viruses that cause dengue fever worldwide. A person infected with one type of dengue will only be immune to that type. Humans and primates are the primary host of the virus, and infection can be acquired by a single bite. A female mosquito becomes infective about eight to twelve days after a blood meal from a person infected with dengue and becomes infected itself with the virus in cells lining its gut, and remains infective throughout its life. During this period, the virus spreads to other tissues including the mosquitos salivary glands and is subsequently released into its saliva. The patients are usually infective from a day before the febrile period to the end of it. The mosquito has fine white dots at the base of its wings with white bands on its legs. It is a day-biting and low-flying mosquito that appears between two hours after sunrise and two hours before sunset. It usually remains one hundred meters of where they hatched. Breeding places include any clear stagnant water along and around the premises of the household. Dengue Hemorrhagic Fever II (A Case Analysis) Page 1

The incubation period (the time between the exposure and the onset of symptoms) is three to fourteen days but most often four to ten days. It is more common in young children between four to nine years old. Both sexes can be affected. It is more frequent during rainy season. Dengue fever is more prevalent in urban communities. It is life-threatening to people with chronic diseases such as diabetes and asthma. Children often experience symptoms similar to common cold and gastroenteritis (vomiting and diarrhea) but are more susceptible to the severe complications. In this case analysis, the researchers had sought information about a 44 year old client whose case is Dengue Hemorrhagic Fever. Upon gathering of data, no rights have been bypassed and all precautions have been foreseen so it would not harm the said client. Herewith the researchers made a plan of care for the benefit of the client. The care consists of a holistic approach so that recovery would be maximized in a short period of time and wellness would be available in no time. This case covers all the conditions of what the client had experienced and it is limited only to the case and anything concerning it. With the help of God, this case study has been made possible.

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 2

Chapter 2

HEALTH HISTORY

A. Biographical Data Patient X is 44 years old, married and was born on June 16, 1967 in Palauig, Zambales. She is a Methodist. Her permanent residency is in Tubotubo South, Santa Cruz Zambales with her husband and their four kids. She works as a server in a canteen at Mariveles Bataan. B. Present Health History Three days prior to admission, Patient X had a fever early in the morning and vomited twice. She sought consultation at the Santa Cruz Hospital for her high grade fever. The doctor wanted to monitor her platelet because she was suspected of Dengue. Her platelet result was 138. Second days prior to admission, Patient X still had a high grade fever and vomited two more times. Her platelet result was 147. Prior to admission, Patient X complained of having pain in the stomach and vomiting. Her platelet dropped to 99 and the doctor referred her immediately to President Ramon Magsaysay Memorial Hospital. September 1st, 2011 on 1:35 pm. early warning signs C. Past Health History Patient X had vaccinations for BCG, DPT, Hepatitis B, and Tetanus Toxoid. She had the measles at age of 6 and the chickenpox when she was 8. She has no known allergies to drugs but she is allergic to bagoong, as manifested by rashes. Her last menstrual period was on August 31, 2011. She She was admitted on

Her admitting diagnosis was Dengue without

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 3

has four children that were all normal deliveries. After the birth of her last child, shes been getting a recurrent urinary tract infection. She never had any serious accidents requiring hospitalizations and except for this present condition she never had the need to be hospitalized for an illness. D. Family Health History Patient X is the eighth child out of nine. She has no known family history of Diabetes Mellitus and Hypertension. Her father died when she was 28 years old due to hydrothorax. He was an avid smoker and had a history of asthma and high blood. Her mother is still alive at the age of 78, and has a history of stroke and anemia. She was also an avid smoker for 62 years. She doesnt know if any of her siblings have any health complications. All of her four children are well and updated in their immunizations (BCG, DPT, OPV, Hepatitis B, and Measles). E. Psychosocial Health History Patient X owns a house in Santa Cruz. Its a cemented house, with two rooms and one bathroom. All her children reside with them and are financially dependent. Patient X also rents a room with her husband in Mareveles Bataan. The boarding house is located in an area where the houses are overcrowded and there arelots of plants and trees. She works as a server in a canteen seven days a week and this is the first time that she got time off from work in the last three months. Patient X states that she and her husband dont drink alcohol or smoke cigarettes. She goes to work daily and does household chores. She doesnt go out much and socialize, but she does like to sing karaoke when she can. Since the age of 16, she had a bad incident where she almost choked on a tablet. Ever since then, she would let nature take its course whenever she got

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 4

a fever, cough or colds. She is also scared of going to the doctor. If it wasnt for her daughter forcing her to go, she would never have gone to get a consultation on her own. F. Dietary Health History Patient X was vomiting on the day of her admission. She felt weak and had poor appetite. But on any other normal day she likes to eat 2 cups of rice, 5 pieces of tuyo, coffee, a glass of water and banana for breakfast. She doesnt have snacks between breakfast and lunch. At lunch time, she likes to eat 2 cups of rice, a bowl of sinigang na baboy, a glass of water and a soft drink. For her afternoon snack, she eats 2 pieces of bread, cup of coffee and glass of water. For dinner, she likes to eat 2 cups of rice, diningding and a glass of water. Patient X doesnt drink enough water daily. At the most, she drinks only four cups of water a day as opposed to 12 cups thats recommended daily. She tries to balance what she eats by eating a serving of vegetables and fruit at least once a day.

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 5

Chapter 3

PHYSICAL ASSESSMENT

General appearance Body built, height, weight in relation to clients age, lifestyle and health

Technique

Normal

Inspection

Proportionate varies with age and lifestyle

Actual findings Build slightly fat

Interpretation Normal

Posture and gait, standing, sitting and walking

Relaxed, erect posture and coordinated movement

Able to sit and walk

Normal

Overall hygiene and grooming Body and breath odor

Clean and neat

Fair hygiene

Normal

No body odor or minor odor related to work or exercise; no breath odor Cooperative and able to follow instruction

No body odor

Normal

Patients attitude

Slightly cooperative

Normal

Patients mood

Appropriate according to situation Understandable, moderate pace, clear tone and exhibits thought association

Irritable

Due to environment changes Normal

Quality, quantity and organization of speech

Moderate pace and soft

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 6

DATE: September 02, 2011 TIME: 8:30 am

Procedure Blood Pressure Pulse Rate Respiration Rate Temperature

Normal <120/80 60-100 16-20 36.5-37.5

Vitals signs 100/70 110 20 38.0 C

Interpretation Normal Increase pulse rate due to fever Normal Febrile

WEIGHT: 62 kg HEIGHT: 54 BODY MASS INDEX: 24.34 Weight Status Body Mass Index < 18.5 18.5 24.9 25 29.9 30 - 40

Underweight Normal Weight Overweight Obesity

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 7

Body part

Technique

Normal

Actual Findings

Interpretation

SKIN Skin color

Inspection

Skin moisture Skin Temperature Skin turgor

Palpation Palpation

Varies from light to deep brown, generally uniform except in areas exposed to the sun Moist skin Within normal range T-36.5-37.5 When pinched skin springs back to previous state Lighter in color Moist/Oily (-) Lice, and dandruff Black or brown Evenly distributed Thick or thin Shape maybe oval and rounded Color depends on race usually black or brown Evenly place in line Not protruding Meets completely when the eyes

With presence of petechiae in the antecubital area

Due to ruptures of tiny capillaries

Dry skin Warm to touch T-38.0 C Skin springs back to previous state immediately Oily hair, no lice or dandruff

Due to fluid loss Due to excessive sweating and vomiting Normal

Palpation

HEAD Scalp

Inspection

Normal

Hair

Inspection

Black and thin hair

Normal

FACE

Inspection

Oval shape

Normal

Eyes

Black and evenly placed in line

Normal

Conjunctiva

Inspection

Reddish in color

Due to inflammation behind the eyes

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 8

Pupils

Inspection

Sclera

Inspection

EARS

Inspection

are closed Transparent with light pink in color Dilates when looking at distant object Constrict when looking at near object Color is white (-) yellowish discoloration Earlobes are bean shaped, parallel and symmetrical Some color as the skin No lesions, discharge or tenderness Same color as the face and skin In the midline No discharge

Reacts to light

Normal

Pinkish in color

Light brown in color

Due to inflammation behind the eyes Normal

Palpation

No discharge or cerumen Light brown in color and without any discharge or bleeding

Normal

NOSE

Inspection

Normal

MOUTH Lips Gums

Inspection Inspection

Pink and moist Dry lips Pinkish color, moist and tightly fit against each tooth No gums bleeding Firmly set and shiny white to yellowish color

Due to lack of fluid intake Slightly pink and Normal no gums bleeding

Teeth

Inspection

Whitish in color and all her teeth are real except for the two central incisors which are dentures

Normal

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 9

Tongue

Inspection

Moist and slightly rough in the surface

NECK

Inspection

Straight and midline Without masses When overlying the breast should be over Nipples are rounded, averted same sized and equal in color (-) Discharge from the nipple

Able to move Normal freely and without presence of cold sores Neck moves Normal freely without discomfort

Palpation BREAST Inspection

Breast are even and no discharge from the nipple

Normal

Palpation ABDOMEN Inspection

(-)tenderness (-) masses Color of skin is Skin is uniform uniform in color Contour maybe flat or rounded No tenderness Presence of petechiae in the upper extremities Quite and clear breath sounds

Normal

EXTREMITIES

Palpation Inspection

LUNGS and THORAX

(-)Tenderness Both extremities equal in sized has equal contraction Auscultation Clear breath sounds Quite, effortless respiration

Normal Due to rupture of tiny capillaries

Normal

MUSCOSKELE TAL Muscle size Inspection Equal in size Moves freely Normal

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 10

on the both side of the body Palpation Deformities Inspection (-)tenderness No deformities and bone contractures

and no deformities and tenderness

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 11

Chapter 4

LABORATORY FINDINGS

A.HEMATOLOGY

Date: Time:

09/01/11 1:15 pm

Test Hematocrit Hemoglobin Leukocyte Count

Normal Value 35-50% 11.0-16.5 g/dL 4.5-11x109/L

Result 48 16.0 5.6

Indication/Interpretation NORMAL NORMAL NORMAL

Differential Count Neutrophils Lymphocytes 0.45-0.73% .20-.35% .72 .28 NORMAL NORMAL DECREASED: May indicate decreased Platelet Count 150-450% 112 platelet production, increased platelet destruction.

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 12

B.HEMATOLOGY

Date: Time:

09/01/11 8:00pm

Test White blood cells Red Blood cells

Normal Value 4.5-11x103/mm3 3.805.80106/mm3

Result 5.2 103/mm3 4.50 106/mm3

Indication/Interpretation NORMAL NORMAL

Hemoglobin Hematocrit Platelet count

11-16.5 g/dl 35-50% 150-450%

12.5g/dl 37.0% 93

NORMAL NORMAL DECREASED: May indicate decreased platelet production, increased platelet destruction

PCT Mean Corpuscular Volume (MCV) Mean corpuscular Hemoglobin (MCH) Mean Corpuscular Hemoglobin Concentration (MCHC) RDW

.100-.500 80-97

.186 L% 82 um3

NORMAL NORMAL

26.5-33.5

27.7pg

NORMAL

31.5-35 g/dl

33.7g/dl

NORMAL

10-15%

14.0%

NORMAL

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 13

MPV PDW

6.5-11 um3 10-18%

7.8um3 10.9%

NORMAL NORMAL

Differential Count Lymphocyte Monocytes 17-48% 4-10% 29.1% 11.4% NORMAL ELEVATED: May indicate infection that may cause monocytosis

C. HEMATOLOGY

Date:

9/01/11

Time: 4:00am

Test White blood cells Red Blood cells Hemoglobin Hematocrit Platelet count

Normal Value 3.5-10x103/mm3 3.80-5.80 11-16.5g/dl 35-50% 150-450 L 10 /mm

3 3

Result 4.2x103/mm3 4.41 12.3g/dl 36.1% 90 L 10 /mm

3 3

Indication/Interpretation NORMAL NORMAL NORMAL NORMAL DECREASED: : May indicate decreased platelet production, increased platelet destruction.

PCT Mean Corpuscular Volume (MCV) Mean corpuscular Hemoglobin(MCH)

.100-.500% 80-97 um
3

.168 L% 82 um
3

NORMAL NORMAL

26.5-33.5 pg

27.8 pg

NORMAL

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 14

Mean Corpuscular Hemoglobin Concentration (MCHC) RDW MPV PDW

31.5-35 g/dl

34.0 g/dl

NORMAL

10-15% 6.5-11 um3 10-18%

14.1% 7.5 um3 8.6 L %

NORMAL NORMAL DECREASED: May indicate a variation in platelet size which can be sign of an active platelet release.

Differential Count Lymphocyte Monocytes 17-48% 4-10% 27.6% 17.1% NORMAL ELEVATED: May indicate infection that may cause monocytosis.

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 15

D.URINALYSIS

Date:

9/01/11

Time: 12:00pm

Macroscopic Examination Color

Normal Findings Amber Yellow

Result Orange

Indication/Interpretation Abnormal: May indicate concentrated urine due to dehydration, fever, bile, excess bilirubin.

Transparency Microscopic Examination Red Blood Cells 5hpf

Turbid

NORMAL

Many

NORMAL: May indicate hematuria.

Pus Cells Epithelial Cells

0-8% <2/hpf

3-5% Few

NORMAL NORMAL

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 16

E.SEROLOGY

Date:

09/02/11

Time: 2:00 pm

Test IgM IgG

Result Negative (-) Negative (-)

Indication/ Interpretation NORMAL NORMAL

F. HEMATOLOGY

Date:

09/02/11

Time: 12:00pm

Test Hematocrit Hemoglobin Leukocyte Count

Normal Value 35-50% 11.0-16.5 g/L 4.5-11x109/L

Result 38% 11.5 g/L 4.0 x109/L

Indication/Interpretation NORMAL NORMAL DECREASED: The body is fighting infection

Differential Count Neutrophils Lymphocytes 0.45-0.73 .20-.35 0.57 0.72 NORMAL Elevated: May indicate an active viral infection. Eosinophils Platelet Count 0.00-0.04 150-450 x109/L 0.01 93 x109/L NORMAL DECREASED: May indicate decreased platelet production, increased platelet destruction.

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 17

G. HEMATOLOGY

Date:

09/02/11

Time: 10:00 pm

Test Hematocrit Hemoglobin Leukocyte Count

Normal Value 35-50% 11.0-16.5 g/L 4.5-11x109/L

Result 38% 11.5g/L 9.5 x109/L

Indication/Interpretation NORMAL NORMAL NORMAL

Differential Count Neutrophils Lymphocytes 0.45-0.73 .20-.35 0.52 0.78 NORMAL ELEVATED: May indicate an active viral infection and exhausted immune system. Platelet Count 150-450 x109/L 93 x109/L DECREASED: May indicate decreased platelet production, increased platelet destruction.

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 18

H. HEMATOLOGY

Date:

09/03/11

Time: 4:00am

Test PROTIME(PT)

Normal Value 14.9-18.5 seconds

Result 11.6 seconds

Indication/Interpretation DECREASED: May indicate reduction in clotting ability of the blood.

% Activity INR Activated Partial Thromboplastin Time (a PTT)

75-130% 1.0 25-43 seconds

124.9% 0.83 53.3 seconds

NORMAL NORMAL ELEVATED: Increased in clotting factor depletion and circulating coagulation.

I. HEMATOLOGY

Date:

09/03/11

Time: 6:00 am

Test Hematocrit Hemoglobin Leukocyte Count

Normal Value 35-50% 11.0-16.5 g/L 4.5-11 x109/L

Result 35% 11.5g/L 10.37 x109/L

Indication/Interpretation NORMAL NORMAL NORMAL

Differential Count Neutrophils 0.45-0.73 0.46 NORMAL

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 19

Lymphocytes

.20-.35 150-450 x109/L

0.54 95 x109/L

ELEVATED: May indicate an active viral infection.

Platelet Count

DECREASED: May indicate decreased platelet production, increased platelet destruction.

J. HEMATOLOGY

Date:

09/04/11

Time: 6:00 am

Test Hematocrit Hemoglobin Leukocyte Count

Normal Value 35-50% 11.0-16.5 g/L 4.5-11 x109/L

Result 40% 14.5g/L 10.5 x109/L

Indication/Interpretation NORMAL NORMAL NORMAL

Differential Count Neutrophils Lymphocytes Platelet Count 0.45-0.73 .20-.35 150-450 x109/L .53 .28 125 x109/L NORMAL NORMAL DECREASED: May indicate decreased platelet production, increased platelet destruction.

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 20

Chapter 5

ANATOMY AND PHYSIOLOGY

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 21

BLOOD Humans can't live without blood. Without blood, the body's organs couldn't get the oxygen and nutrients they need to survive. We couldn't keep warm or cool off, fight infections, or get rid of our own waste products. Without enough blood, we'd weaken and die. Here are the basics about the mysterious, life-sustaining fluid called blood.

Blood Basics Two types of blood vessels carry blood throughout our bodies: 1. Arteries carry oxygenated blood (blood that has received oxygen from the lungs) from the heart to the rest of the body. 2. Blood then travels through veins back to the heart and lungs, where it receives more oxygen. As the heart beats, you can feel blood traveling through the body at pulse points like the neck and the wrist where large, blood-filled arteries run close to the surface of the skin. The blood that flows through this network of veins and arteries is whole blood, which contains three types of blood cells: 1. red blood cells (RBCs) 2. white blood cells (WBCs) 3. platelets In babies and young kids, blood cells are made within the bone marrow (the soft tissue inside of bones) of many bones throughout the body. But, as kids get older, blood cells are made mostly in the bone marrow of the vertebrae (the bones of the spine), ribs, pelvis, skull, sternum (the breastbone), and parts of the humerus (the upper arm bone) and femur (the thigh bone). The cells travel through the circulatory system suspended in a yellowish fluid called plasma, which is 92% water and contains nutrients, proteins,

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 22

hormones, and waste products. Whole blood is a mixture of blood cells and plasma. Red Blood Cells Red blood cells (also called erythrocytes) are shaped like slightly indented, flattened disks. RBCs contain the iron-rich protein hemoglobin. Blood gets its bright red color when hemoglobin picks up oxygen in the lungs. As the blood travels through the body, the hemoglobin releases oxygen to the tissues. The body contains more RBCs than any other type of cell, and each has a life span of about 4 months. Each day, the body produces new RBCs to replace those that die or are lost from the body. White Blood Cells White blood cells (also called leukocytes) are a key part of the body's system for defending itself against infection. They can move in and out of the bloodstream to reach affected tissues. Blood contains far fewer WBCs than red blood cells, although the body can increase WBC production to fight infection. There are several types of WBCs, and their life spans vary from a few days to months. New cells are constantly being formed in the bone marrow. Several different parts of blood are involved in fighting infection. White blood cells called granulocytes and lymphocytes travel along the walls of blood vessels. They fight germs such as bacteria and viruses and may also attempt to destroy cells that have become infected or have changed into cancer cells. Certain types of WBCs produce antibodies, special proteins that recognize foreign materials and help the body destroy or neutralize them. The white cell count (the number of cells in a given amount of blood) in someone with an infection often is higher than usual because more WBCs are being produced or are entering the bloodstream to battle the infection. After the body has been challenged by some infections, lymphocytes "remember" how to make the specific antibodies that will quickly attack the same germ if it enters the body again.

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 23

Platelets Platelets (also called thrombocytes) are tiny oval-shaped cells made in the bone marrow. They help in the clotting process. When a blood vessel breaks, platelets gather in the area and help seal off the leak. Platelets survive only about 9 days in the bloodstream and are constantly being replaced by new cells. Important proteins called clotting factors are critical to the clotting process. Although platelets alone can plug small blood vessel leaks and temporarily stop or slow bleeding, the action of clotting factors is needed to produce a strong, stable clot. Platelets and clotting factors work together to form solid lumps to seal leaks, wounds, cuts, and scratches and to prevent bleeding inside and on the surfaces of our bodies. The process of clotting is like a puzzle with interlocking parts. When the last part is in place, the clot happens but if even one piece is missing, the final pieces can't come together. The body may not be able to repair itself through clotting alone, if large blood vessels are severed (or cut). In these cases, dressings or stitches are used to help control bleeding. Nutrients in the Blood Blood contains other important substances, such as nutrients from food that has been processed by the digestive system. Blood also carries hormones released by the endocrine glands and carries them to the body parts that need them. Blood is essential for good health because the body depends on a steady supply of fuel and oxygen to reach its billions of cells. Even the heart couldn't survive without blood flowing through the vessels that bring nourishment to its muscular walls. Blood also carries carbon dioxide and other waste materials to the lungs, kidneys, and digestive system to be removed from the body.

Blood cells and some of the special proteins blood contains can be replaced or supplemented by giving a person blood from someone else via a

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 24

transfusion. In addition to receiving whole-blood transfusions, people can also receive transfusions of a particular component of blood, such as platelets, RBCs, or a clotting factor. When someone donates blood, the whole blood can be separated into its different parts to be used in this way.

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 25

Component Water Electrolytes

Nutrients

Wastes Proteins Albumins: Transports lipids Globulins: Transports ions, hormones, and lipids Fibrinogen: Essential component of clotting system

Composition of whole blood Function PLASMA Dissolves and transports molecules, blood cells, and heat Normal extracellular fluid ion composition essential for vital cellular activities Used for energy production, growth, and maintenance of cells Travel to sites of excretion

Red blood cells White blood cells Granulocytes Nuetrophils Eosinophils Basophils Agranulocytes Monocytes Lymphocytes Platelets

Formed Elements Transports oxygen and carbon dioxide

Engulf debris and pathogens Engulf items coated in antibodies Stimulate inflammation on tissues by releasing histamines Engulf debris and pathogens Immune defense against pathogens, toxins, and foreign substances Participate in clotting response

Dengue Hemorrhagic Fever II (A Case Analysis)

Page 26