DENGUE

SUBMITTED BY:
Ernest John Gomez
BSN 615B

SUBMITTED TO:
Mr. Mirador

GENERAL DATA
1. PATIENT NAME: R. M.
2. ADDRESS: Valenzuela
3. AGE: 18 years old
4. NATIONALITY: Filipino
5. CIVIL STATUS: Single
6..DATE OF ADMISSION: September 15,2015
7. ORDER OF ADMISSION:
Admit to ward
Secure consent
TPR q4 every shift
Diagnostics: CBC, platelet, urinalysis
8. ADMITTING DIAGNOSIS: Fever for 3days

CHIEF COMPLAINT
Intermitent fever for 3days
HISTORY OF PRESENT ILLNESS
a day prior to admission the patient experienced hyperthermia.
PAST HEALTH HISTORY/STATUS
He didnt have any operations, surgeries or any allergies to food or drugs. He had measles, mumps and common colds. He has been immunized and
completed vaccinations for Bacillus Calmette Guerin (BCG), Oral Polio Virus (OPV), Diphtheria, Pertusis, andTetanus (DPT), Hepatitis B and MMR.

PHYSICAL ASSESSMENT
VITAL SIGNS
BP: 120/80mmHg
PR: 80 beats per minute
RR: 24 breaths per minute
TEMP: 38.2 degree Celsius
PERSONAL / SOCIAL HISTORY
a. Habits/ Vices: watching television, playing.
a. Caffeine: not drinking coffee
b. Smoking: not smoking
c. Alcohol: not drinking alcohol
d. Tea: not drinking tea.
E. drugs none
b. Lifestyle
When staying in house he watches television or going out with friends.
c. Social Affiliation
He doesnt participate in any affiliations.
d. Rank in the family
He is youngest among two siblings
e. Travel (within 6 months)
He didnt travel.
f. Educational Attainment
High School

INTRODUCTION
Dengue Fever is caused by one of the four closely related, but antigenically distinct, virusserotypes Dengue type 1, Dengue type 2, Dengue type
3, and Dengue type 4 of the genus Flavivirus and Chikungunya virus. Infection with one of these serotype provides immunity toonly that serotype of life, to
a person living in a Dengue-endemic area can have more than oneDengue infection during their lifetime. Dengue fever through the four different Dengue
serotypesare maintained in the cycle which involves humans and Aedes aegypti or Aedes albopictusmosquito through the transmission of the viruses to
humans by the bite of an infected mosquito.The mosquito becomes infected with the Dengue virus when it bites a person who has Dengueand after a
week it can transmit the virus while biting a healthy person. Dengue cannot betransmitted or directly spread from person to person. Aedes aegypti is
the most common aedesspecie which is a domestic, day-biting mosquito that prefers to feed on humans.

INTUBATION PERIOD: Uncertain. Probably 6 days to 10 days

PERIOD OF COMMUNICABILITY: Unknown. Presumed to be on the 1st week of illness when virus is still present in the blood
CLINICAL MANIFESTATIONS:
First 4 days:
>febrile or invasive stage --- starts abruptly as high fever, abdominal pain and headache; later flushing which may be accompanied by vomiting,
conjunctival infection and epistaxis
4th to 7th day:
>toxic or hemorrhagic stage --- lowering of temperature, severe abdominal pain, vomiting and frequent bleeding from GIT in the form of melena;
unstable BP, narrow pulse pressure and shock; death may occur; vasomotor collapse
7th to 10th day:
>convalescent or recovery stage --- generalized flushing with intervening areas of blanching appetite regained and blood pressure already
stable
MODE OF TRANSMISSION:
Dengue viruses are transmitted to humans through the infective bites of female Aedesmosquito. Mosquitoes generally acquire virus while feeding
on the blood of an infected person. After virus incubation of 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.
Humans are the main amplifying host of the virus. The virus circulates in the blood of infected humans for two to seven days, at approximately
the same time as they have fever. Aedesmosquito may have acquired the virus when they fed on an individual during this period. Dengue cannot be
transmitted through person to person mode.
CLASSIFICATION:
1. Severe, frank type
>flushing, sudden high fever, severe hemorrhage, followed by sudden drop of temperature, shock and terminating in recovery or death
2. Moderate
>with high fever but less hemorrhage, no shock present
3. Mild
>with slight fever, with or without petichial hemorrhage but epidemiologically related to typical cases usually discovered in the course of invest or
typical cases
GRADING THE SEVERITY OF DENGUE FEVER:
Grade 1:
>fever
>non-specific constitutional symptoms such as anorexia, vomiting and abdominal pain

>absence of spontaneous bleeding>positive tourniquet test

Grade 2:
>signs and symptoms of Grade 1: plus
>presence of spontaneous bleeding: mucocutaneous, gastrointestinal
Grade 3:
>signs and symptoms of Grade 2 with more severe bleeding: plus>evidence of circulatory failure: cold, clammy skin, irritability,
weak tocompressible pulses, narrowing of pulse pressure to 20 mmhg or less, coldextremities, mental confusion
Grade 4:
>signs and symptoms of Grade 3, declared shock, massive bleeding, pulse lessand arterial blood Pressure = 1 mmhg (Dengue Syndrome/DS)
SUSCEPTABILITY, RESISTANCE, AND OCCURRENCE:
>all persons are susceptible
>both sexes are equally affected>age groups predominantly affected are the pre-school age and school age>adults and infants are not
exempted
>peak age affected: 5-9 years old
DF is sporadic throughout the year. Epidemic usually occurs during rainy seasons (June November). Peak months are September October. It occurs
wherever vector mosquito exists.
DIAGNOSTIC TEST:
Tourniquet tes
>Inflate the blood pressure cuff on the upper arm to a point midway between thesystolic and diastolic pressure for 5 minutes.
>Release cuff and make an imaginary 2.5 cm square or 1 inch square just belowthe cuff, at the antecubital fossa.
>Count the number of petechiae inside the box. A test is positive when 20 or more petechiae per suare are observed.
Dengue haemorrhagic fever (DHF), a potentially lethal complication, was firstrecognized in the 1950s during the dengue epidemics in the
Philippines and Thailand, but todayDHF affects most Asian countries and has become a leading cause of hospitalization and deathamong children in
several of them.
ANATOMY AND PHYSIOLOGY
The Immune System
A second line of defense is housedwithin the body: a finely tuned
immunesystem that recognizes and destroysforeign substances and
organisms thatenter the body. The immune system
candistinguish between the body's owntissues and outside substances c
alledantigens. This allows cells of theimmune army to identify and destro
yonly those enemy antigens. The abilityto identify an antigen also permits
theimmune system to "remember" antigensthe body has been exposed
to in thepast; so that the body can mount abetter and faster immune

response thenext time any of these antigens appear.The immune system

also includes
other proteins and chemicals that assistantibodies and T cells in their wor
k.Among them are chemicals that alertphagocytes to the site of the
infection.The complement system, a group of proteins that normally float
freely in the blood, move toward infections, where theycombine
to help destroy microorganisms and foreign
particles. They do this bychanging the surface of bacteria or other
microorganisms, causing them to die.

PATHOPHYSIOLOGY
Medical Diagnosis
T/C Dengue Hemorrhagic Fever/ Pleural Effusion, T/C Liver Pathology
Definition

Dengue Hemorrhagic Fever is a severe, potentially deadly infection spread by certain species of mosquitoes (Aedesaegypti).
Pleural Effusion is excess fluid that accumulates in the pleural cavity, the fluid-filled space that surrounds the lungs.Excessive amounts of such fluid can impair breathing
by limiting the expansion of the lungs during inhalation.
Liver Pathology
a condition characterized by any liver diseases or condition

Predisposing
Geographicacl area tropical islands
in thePacific (Philippines) and Asia

Aedesaegypti (dengue virus carrier) 812 days of viral replication on

mosquitos salivary glands

Bite from mosquito (portal of entry in

the skin)

Allowing dengue virus to be inoculated

towards the circulation/blood
(incubation days 3-14 days)

Redness and itchiness in the area

Virus disseminated rapidly into the blood and stimulates WBCs

including B-lymphocytes that produces and secretes immunoglobulin
(antibodies), and monocytes, macrophages and neutrophils monocyte.

Antibodies attach to the viralantigens, and

thenmonocytes/macrophages willperform
phagocytosis through Fcreceptor (FcR)
within the cells anddengue virus replicates in
the cells

DRUG STUDY
Generic name: ceftriaxone sodium
Brand name: Rocephin
Drug Classification: Antibiotic, Cephalosporin (third generation)
Dosage: 1 amp IV q 12 h, ANST (-)
Indication: Urinary tract infection
MECHANISM OF
ACTION
Bactericidal: Inhibits

SIDE EFFECT

Nausea, vomiting,

CONTAINDICATIONS

ADVERSE REACTION

Contraindicated

CNS: headache, dizziness, lethargy,

NURSING
CONSIDERATIONS

Teaching points:

synthesis of cell wall

causing cell death

diarrhea, anorexia,
abdominal
pain,
flatulence
Ranging from rash
to fever
Pain, phlebitis
Super
infections,
desulfiram-like
reaction
with
alcohol

with allergy to
cephalosporins or
penicillins.Use
cautiously with
renal failure.

paresthesias
You may experience
these side effects:
stomach upset or
diarrhea
Report severe
diarrhea, difficulty
breathing, unusual
tiredness or fatigue,
pain at injection site.

GI: Nausea, vomiting, diarrhea,

anorexia, abdominal pain, flatulence,
pseudomembranous colitis, liver
toxicity
GU: nephrotoxicity
Hematologic: Bone marrow
depression decreased WBC,
decreased platelets, decreased Hct.
Hypersensitivity: Ranging from rash
to fever to anaphylaxis; serum
sickness reaction

Discontinue if
hypersensitivity reaction
occurs.

Local: Pain, abscess at injection site;

phlebitis, inflammation at IV site
Other: Super infections, desulfiramlike reaction with alcohol.

Generic name: paracetamol

Brand name:Flugard
Drug classification: antipyretic, analgesic (non opioid)
Dosage: IV 1 amp now then PRN fer fever
Indications: for fever
MECHANISM OF
ACTION
Antipyretic: reduces
fever by acting directly

SIDE EFFECT

none

CONTAINDICATIONS

Contraindicated
with allergy to

ADVERSE REACTION
CNS: headache

NURSING
CONSIDERATIONS
Assessment:
History: allergy to

on the hypothalamic
heat-regulating center to
cause vasodilation and
sweating, which helps
dissipate heat.
Analgesic: site and
mechanism action
unclear.

acetaminophen.
Use cautiously
with impaired
hepatic function,
chronic
alcoholism,
pregnancy,
lactation.

CV: chest pain, dyspnea,

myocardial damage when
doses of 5-8 g/day are
ingested daily for several
weeks or when doses of 4
g/day are ingested for 1 year.
GI: Hepatic toxicity and
failure, jaundice
GU: acute renal failure, renal
tubular necrosis.
Hematologic:
methemoglobinemia
cyanosis; hemolytic anemia
hematuria; anuria;
neutropenia,
leukopenia,thrombocytopeni
a, hypoglycemia
Hypersensitivity: rash, fever

ONGOING APPRAISAL
The patient is responding well to both medical and nursing intervention.

acetaminophen,
impaired hepatic
function.
Physical: skin
color, lesions, T;
liver evaluation;
CBC, LFTs, renal
function tests.

DISCHARGE PLAN (HEALTH TEACHING)

Medication: Instruct IE.DR to take all the necessary medicines that the doctors prescribed.
Treatment: Instruct to follow all prescribed therapeutic regimens.
Clinical follow up: Instruct the patient to come back on scheduled follow up check.
Diet: Advise to eat dark green leafy vegetables, rich in iron and vitamin C diet to regain strength and boost his immune system
Danger Signs: Instruct the patient to seek medical advice if he is experiencing excessive nose bleeding and high-grade fever and appearance of rashes.

PATHOPHYSIOLOGY ( in diagram )

Dengue infection

Antibody formation

Reinfection

Augmentation of virus multiplication

Increased vascular permeability

Reduce Platelets

Plasma Leakage

Coagulopathy

Hypovolemia

Disseminated intravascular coagulation

Shock

Severe Bleeding

Death