DENGUE

HEMORRAGHIC
FEVER

A Case Study Presented

Siena College Taytay, Rizal

In Partial Fulfillment of the Requirements

For the degree - Bachelor of Science in Nursing

Karlo G. Bartolome

September 24, 2010

 Introduction

NTRODUCTION

Dengue Fever is caused by one of the four closely related, but antigenically
distinct, virus serotypes 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 to only that serotype of life, to a person living
in a Dengue-endemic area can have more than one Dengue infection during their
lifetime. Dengue fever through the four different Dengue serotypes are maintained
in the cycle which involves humans and Aedes aegypti or Aedes albopictus
mosquito 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 Dengue and after a week it can transmit the virus while
biting a healthy person. Dengue cannot be transmitted or directly spread from
person to person. Aedes aegypti is the most common aedes specie 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:
MODE OF TRANSMISSION:

Dengue viruses are transmitted to humans through the infective bites of

female Aedes mosquito. 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. Aedes mosquito 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 cas

Dengue haemorrhagic 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.

Last June 16, 2008, I encountered a patient with such kind of infection. This
patient has caught my attention and has given the opportunity to study his case.
The objective of this study is to help me understand the disease process of Dengue
Fever and to orient myself for appropriate nursing interventions that I could offer
to the patient. This approach enables me to exercise my duties as student nurse
which is to render care. I was given the chance to improve the quality of care I can
offer and to pursue my chosen profession as future nurse.

I humble myself to present my studied case and submit myself for further
corrections to
widen the scope of my knowledge and understanding.
 Objectives

Objectives of this case study were based on 11 competency standards of nursing practice.

General Objectives

• This case study aims to develop the application of critical and analytical thinking in the

nursing practice.

Specific Objectives

• To practice safe and quality nursing care by formulating Nursing Care Plans

• To give health education by performing health teaching with the patient and his family

• To practice legal and ethico-moral responsibility by documenting care rendered to the

patient

• For personal and professional development.

• Promotion of quality nursing service.

• To apply research findings in nursing practice

• To improve record management by maintaining accurate and updated documentation of

patient care

• To practice therapeutic communication with the client.

• To establish collaborative relationship with colleagues and other members of the health

team for the health plan

 Significance of the study

To Nursing Students, It will help develop analytical and critical thinking by understand the

disease through anatomy and pathophysiology, analyzing the proper care to the patient by

formulating nursing care plans, drug study and recording the condition of the client by physical

examination, patient’s profile and activities in daily living.

To Nursing Educators, it will aid in identifying vital competencies to be developed in nursing

students, particularly proficiency of roles and functions in patient care and supervision.

To Hospital Management, It will contribute in improving quality of care to the patients by

applying nursing interventions mentioned in the case study.

To the Readers, It will serve as a guide in understanding more about peptic ulcer and its proper

nursing ,medical and collaborative management.

Scope and delimitations

The study was conducted in medical Ward of Rizal Provincial Hospital last September
24, 2010. The study focused on patient with Dengue Hemorrhagic fever. The topics to be
discussed are: Introduction, Theoretical Framework, Pathophysiology, Anatomy & Physiology,
and Patient’s History, Physical Assessment, Hematology, Drug study, Discharge Plan and the
Nursing Care Plan. All subjects discussed, nursing interventions and recorded data were limited
and based on the patient’s condition.
 Theoretical Framework

14 Functions of Nursing Care

By
Virginia Henderson
(1897 – 1996)

Virginia Henderson graduated from the Army School of Nursing, Washington, D.C., in
1921.Virginia Henderson defined nursing as "assisting individuals to gain independence in
relation to the performance of activities contributing to health or its recovery". Her famous
definition of nursing was one of the first statements clearly delineating nursing from
medicine:"The unique function of the nurse is to assist the individual, sick or well, in the
performance of those activities contributing to health or its recovery (or to peaceful death) that
he would perform unaided if he had the necessary strength, will or knowledge and to do this in
such a way as to help him gain independence as rapidly as possible" (Henderson, 1966). She was
one of the first nurses to point out that nursing does not consist of merely following physician's
orders. Henderson enumerated the 14 functions she believed to be part of basic nursing care. The
nurse should help the patient to perform the following functions:

The 14 components

• Breathe normally.
• Eat and drink adequately.
• Eliminate body wastes.
• Move and maintain desirable postures.
• Sleep and rest.
• Select suitable clothes-dress and undress.
• Maintain body temperature within normal range by adjusting clothing and modifying
environment
• Keep the body clean and well groomed and protect the integument
• Avoid dangers in the environment and avoid injuring others.
• Communicate with others in expressing emotions, needs, fears, or opinions.
• Worship according to one’s faith.
• Work in such a way that there is a sense of accomplishment.
• Play or participate in various forms of recreation.
• Learn, discover, or satisfy the curiosity that leads to normal development and health and
use the available health facilities.
Eliminate body Move and maintain
wastes. desirable postures.
Breathe normally.

Eat and drink

adequately. Sleep and rest

Learn, discover, or
satisfy the curiosity Select suitable
that leads to normal clothes-dress and
development undress

Play or participate in
Maintain body
various forms of
temperature within
recreation
HUMAN normal range

Keep the body well

Work in such a way
groomed and protect
that there is a sense
the integument
of accomplishment

Communicate with
Avoid dangers in the
Worship according to others in expressing
environment and
one’s faith emotions, needs,
avoid injuring others
fears, or opinions
Synthesis

Virginia Henderson’s theory is very applicable to this case study. The patient was
admitted in the surgery ward for a very long time and in order to give holistic care to the patient
the nurse must consider the 14 functions of nursing care.

• The patient must breathe normally which means the nurse must monitor the client’s
respiratory rate. It should be in the normal rate of 12-20 breaths per minute.
• The patient must eat and drink adequately. The nurse must consider that the patient is
diabetic and hypertensive so it means the nurse should only allow foods that have low
glucose (carbohydrates), sodium and encourage nutritious food for the patient. The
patient is also encouraged to eat egg white because it is rich in albumin and the patient is
experiencing hypoalbuminemia.
• In elimination of body waste the nurse must monitor the output of the patient if it is
normal. The patient must have urine output of 30ml/hour and defecate at least once a day.
• The nurse must also move and maintain posture of the patient comfortably.
• The nurse must ensure that the patient is have an adequate sleeping and resting time
while in the hospital.
• The nurse must know if the patient is comfortable in his clothing in the hospital.
• The nurse must monitor the patient’s temperature. An elevation of temperature may
indicate infection.
• The nurse must give the patient proper skin care specially the client is diabetic and got a
punctured wound which means the healing is slower.
• The nurse must ensure the patient is safe from injuries while in the ward by securing the
bed rails etc.
• The nurse must practice therapeutic communication with the patient. The patient might
be experiencing anxiety due to prolong stay in the hospital.
• The nurse must not also give physiological care but also spiritual care to the patient and
respect the belief or faith of the patient.
 • The nurse must provide recreational activities during the patients stay in the ward like
reading.

PHYSICAL ASSESSMENT

The patient was assessed last September 3, 2010.

BODY PART METHODS NORMAL ACTUAL ANALYSIS

USED FINDINGS FINDINGS
HEAD
HAIR Inspection Black evenly Presence of Changes in hair
distributed and white hairs and color typically
covers the whole unevenly occur naturally as
scalp, thick, distributed. people age,
shiny. Free from eventually turning
split ends. the hair gray and
then white
(melanin
production ceases).
This is called
achromotrichia.
FACE Inspection Oblong or oval Oblong shape, Because of
square or heart facial irritation
shape, expression
symmetrical looks tired and
facial expression discomfort,
that is dependent and
on the mood or
true feelings,
smooth and free
from wrinkles, no
involuntary
muscle movement
TEETH Inspection 32 permanent 32 permanent normal
teeth, well complete
aligned, free from
caries or filling,
no halitosis.
THORAX &
LUNGS
Breathing Inspection Normal RespiratoryRespiratory rate is
Respiratory rate: rate of 18 the number of
12-20 breaths per breaths per
breaths patient
minute minute. takes within a
certain amount of
time (frequently
given in breaths
per minute).
Average normal
respiratory rates
for adults are 12-
20 breaths per
minute.
Heart rate Auscultation Normal Heart Heart rate of No noticeable
rate: 60-100 beats 72 beats per alterations in the
per minute minute. patient’s heart rate.

Blood Pressure Auscultation Normal blood 120/80 normal

pressure: 120/80
ABDOMEN Inspection, Skin is Skin is a little Skin is slightly dry
Palpation, unblemished, dry, color is because skin loses
Auscultation, & color is uniform, uniform, flat moisture and
Percussion flat rounded, rounded, elasticity
symmetrical symmetrical
movement cause movement
by respiration cause by
respiration
EXTREMITIES
Palms and Inspection & Palm pinkish and Pinkish, warm Palms are hard
dorsal surface Palpation warm and a little because of the
hard patient’s nature of
work.
Legs Inspection/ Tan, skin is Both legs are Because of trauma
palpation smooth hair equally
evenly distributed movable
absence of
varicose veins
Pathophysiology
DRUG ACTION INDICATIO CRONTRAINDICATI SIDE NURSING
NAME N ON EFFECT CONSIDERATI
ON
Ranitidine Competitivel Active Contraindicated EENT: Assess
Hydrochlorid y duodenal in patients Blurred vision patient for
e inhibits and gastric hypersensitive Hepatic: abdominal
Brand: action ulcer to drug and jaundice pain. Note
Zantac of histamine Used to those with with Other: presence of
Dosage: on prevent ulcer acute porphyria burning and emesis, stool, or
50 mg I.V the H2 while patient itching at gastric .aspirate
Classificatio receptor is Use cautiously injection • Proper used
n: sites of on NPO in patients with site, of OTC
Gastrointestin parietal hepatic anaphylaxis,a preparation
al drug (Anti- cells, dysfunction. ngioe as indicated.
ulcer drug decreasing Adjust dosage dema • Take once daily
gastric acid in patients prescription drug
secretion withimpairedren at bed time for
best results
• Instruct
patient to
take without
regard to
meals
because
absorption
isn’t affected
by food.
DRUG NAME ACTION INDICATION CRONTRAINDICA SIDE EFFECT NURSING
TION CONSIDERATION
GENERIC NAME: Gastric Indicated for: Contraindicated with CNS: C: Antisecretory
Omeprazole acid-pump y Short-term hypersensitivity to Headache, drug;
BRAND NAME: inhibitor: treatment of omeprazole or its dizziness, Proton pump
Losec (CAN) Suppresse activeduodenal components; asthenia, inhibitor
DRUG s gastric ulcer; Use cautiously with vertigo, H: IVTT
CLASSIFICATION: acid First-line therapy pregnancy, insomnia, E: decrease gastric
Antisecretory drug secretion in lactation. apathy, anxiety, acid
Proton pump inhibit by specific treatment of paresthesias, secretion
inhibition heartburn or dream C: Take the drug
DOSAGE: 40g of the symptoms of abnormalities before
FREQUENCY: OD hydrogen- gastroesophageal Dermatologic: meals.
ROUTE: IVTT potassium reflux Rash, Report severe
ATPase disease (GERD); inflammation, headache,
enzyme y Short-term urticaria, worsening of
system at treatment of pruritus, symptoms, fever,
the active benign alopecia, dry chills.
secretory gastric ulcer; skin K: Swallow the
surface of yGERD, severe GI: Diarrhea, capsules whole; do
the gastric erosive abdominal not
parietal esophagitis, poorly pain, nausea, chew, open, or
cells; responsive vomiting, crush
blocks the symptomatic constipation, the
final step GERD; dry mouth,
of acid y Long-term tongue atrophy
productio therapy: Respiratory:
Treatment of URI symptoms,
pathologic cough, epistaxis
hypersecretory Other: Cancer
conditions in
(Zollinger-Ellison preclinical
syndrome, multiple studies,
adenomas, back pain, fev
systemic
mastocytosis);
y Eradication of H.
pylori
with amoxicillin or
metronidazole and
clarithromycin
PATIENT’S PROFILE

Name: Mr X
Age: 21
Gender: male
Address: 14 dalig st. Teresa, Rizal
Date of Birth: September 9, 1987
Place of Birth: Muntinlupa City
Nationality: Filipino
Religion: Roman Catholic
Civil Status: Single
Date of Admission:
Time of admission:
Physician:
Place of Admission: Rizal Provincial Hospital
Admitting Diagnosis: Dengue Fever Syndrome

HISTORY OF PRESENT ILLNESS

The patient is a 21 year-old male, a grade three student who was diagnosed with Dengue Hemorrhagic
Fever II. Five days prior to admission the client suffers from having a high fever with a temperature of39.
4 degrees celcius, Paracetamol was given for relief. After three days the fever subsidesandabdominal pain
and vomiting of brownish colored vomitus takes place.Due to persistence of the saidsigns and symptoms,
the patient seek consultation and hence admitted at Rizal Provincial Hospital Dr. San Jose as her
attending physician.

Upon admission the child has experienced gum bleeding with presence of petechiae over theface and
lower extremities accompanied by loss of appetite. Hematology examination shows lowplatelet count
with a value of 100 mm3.During the interview session she has a fever and experiences no gum bleeding at
all. Herabdominal pain becomes intermittent.

PAST MEDICAL HISTORY

According to the patient’s mother, she experienced having urinary tract infection when she wasfive years
old. The patient only experiences having common cough and colds occasionally. She alsoexperiences
fever before and it was relieved by over the counter drugs and rest. Their family does notseek
consultation for regular health check up. She has not been hospitalized and only seeks consultationto their
Baranggay Health Center whenever any health problem arises. She did not receive animmunization
vaccine for measles. She also denies having allergies to food and drugs. She says that sheis allergic to
dust and particles
LABORATORY FINDINGS:
RESULT NORMAL FINDINGS ANALYSIS
Increased due to
presence of infection
10.2 g/dL F: 13.0-18.0 g/dL Decreased due to
Hemoglobin bleeding or
hemorrhage
31 % 39-54 % Decreased due to
Hematocrit bleeding or
hemorrhage

0.73 0.60-0.70 Increased due to high

Segmenters glucose level in the
blood
0.27 0.20-0.30
Lymphocytes l
Due to presence of
100 x 10^g/dL 150-450 x 10^g/ bleeding
Platelet count
DISCHARGE TEACHING

Medication

Remindto take the prescribed medicine, having a written reminder of the correct medication,
time to
take, and the right frequency of the medicine on the way home to establish assurance of
medication
compliance.

Don’t give aspirin and NSAID’s, they increase the risk of bleeding. Any medicines that decrease

platelet count should be avoided.

Exercise

Instruct to avoid excessive activities that may result to stress.

Just advised to perform range of motions and repetitive body movements for promotion of
optimum

Health Teaching.
Remind about the need for health promotion activities such as reading, watching T.V, etc.

Treatment
Bed rest is advisable during the re-occurrence of fever phase.

Instruct to drink plenty of water or fluids that are available at home and eat nutritious diet.

Advised to look for re-occurrence of danger signs and symptoms and report immediately.

Hygiene

Encourage to continue the routinely hygienic care of the patient

Out-Patient Follow-Up Care

Instruct the family members to have a check-up or to consult physician once a while to
monitorpatient’s condition and for detection of recurrences and other complications that may
arise on to it

DIET

Instruct the family members to give the client protein rich foods such as meat, fish,eggs and nuts.
ASESSMENT DIAGNOSIS ANALYSIS INTERVENTION RATIONALE EVALUATION
Subjective: Acute pain This is due to Independent: Goal Partially
“Masakitang related to Entry of >monitor v/s > To determine met,
tiyanko” as inflammatory pathogens alteration in After 30 hour
verbalized by response as in circulation >Instructed to present of nursing care
the evidenced by leading to deep breathing condition the patient
patient. verbalization release of excersise was able to
Objective: of patient “ anti- reduced pain
>C pain scale masakitpo inflammatory >Encourage to >Helps relieving felt from 7/10
of tiyanko” pain mediators and have Diversional pain to 5/10 as
7/10 scale of 7/10, as a activities like evidenced
>grimace grimace & vascular watching t.v. verbalization
noted irritabilit response it of the patient
>irritable cause increase >Place patient in >To divert
>weakness in a comfortable attention
noted capillary position from and reduce
Characteristic: permeability pain felt
Stabbing, leading to >Encourage to
shooting pain hyperemia and have adequate >To provide
Onset: cellular bed rest comfort
“pasumpong exudation,
sumpongpo swelling and pai >Provided
eh” therapeutic touch >To have energy
as verbalized
by Dependent:
patient >Administered
Location: Ranitidine as > Helps in
No exact ordered relieving
Location” sa pain
buongtiyanpoh
as
verbalization
Duration: 2-3
minutes
Exacerbations:
Gets worst
when
pressure is
applied in th
GORDON’S 11 FUNCTIONAL HEALTTH PATTERN
HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

Before hospitalization:

The patient perceived his health in the state of good condition. He perceives health as
wealth and he values his health a lot. He manages his health by practicing proper hygiene and
eating nutritious food.

During hospitalization:

He sees himself as a total ill person because he cannot do anymore the things he usually
does like playing with his siblings. He rely his present condition with the help of the therapeutic
personnel and by following the prescribed medications. The patient perceived that he is not
healthy because of his condition.

NUTRITIONAL-METABOLIC PATTERN
Before hospitalization:

The patient eats 3 times a day and with afternoon snacks after coming from school.
According to the SO of the patient, he eats meat, fish and also vegetables. He doesn’t have any
allergies on foods and drugs. His appetite is moderate and usually depends on the food being
served. He didn’t complain any difficulty in swallowing.

During hospitalization:
The patient has loss his appetite and hasn’t eaten a lot. He is on a DAT (Diet as
Tolerated) EDCF (Except Dark Colored Foods).
ELIMINATION PATTERN
Before hospitalization:

The patient does not have any problem on his elimination pattern. He usually urinates 4-
5 times a day without any difficulty. He added that the color of his urine is light yellow. He
didn’t feel any pain in urination. The patient defecates once a day usually early in the morning
before going to school with yellow to brown color. He verbalized that sometimes however, it is
hard in consistency with dark color, which generally depends on what he eats.

During hospitalization:
The patient urinates 2-3 times a day. The color of her urine is yellow. The patient
defecates once every two days.

ACTIVITY-EXERCISE PATTERN
Before hospitalization:
He could perform activities of his daily living. According to him, he often plays
with his siblings and this serves as a form of exercise for him.
During hospitalization:
His activity was limited lying on bed but the patient is given his bathroom
privileges.

SLEEP-REST PATTERN
Before hospitalization:

He has the normal 6-8 hours sleep. He also has his nap time for 1-2 hours a day.
Sleeping and watching the television are his form of rest.
During hospitalization:

He doesn’t have the adequate time of sleep since he is disturbed with the nurses that
enter the room every now and then, and because of the environmental changes of his
surroundings. He also has inadequate time to rest since he doesn’t have enough time to sleep.

COGNITIVE-PERCEPTUAL PATTERN
Before hospitalization:

He is normal in terms of his cognitive abilities. He has good memory and reasoning
skills. He can easily comprehend on things. In terms of his perceptual pattern, he has no
problems with his senses.

During hospitalization:

He was normal as before in his cognitive and perceptual pattern. He responds clearly and
well understood. He has no sensory deficit; He responds appropriately to verbal and physical
stimuli and obeys simple commands.

SELF-PERCEPTION – SELF-CONCEPT PATTERN

He sees himself as a person with a good personality. He has been a good friend, brother
and a son. He said he has to be a good person in order not to hurt others. He also describes
himself as a typical type of student and person.

ROLE-RELATIONSHIP PATTERN
Before hospitalization:

He has a close relationship with his family. They were five siblings in their family. He
was at the middle. I was also able to ask his mother about his being a son and she confessed that
he is a good son but at times he doesn’t obey her. He is also a responsible student and knows all
his duties as a friend.
During hospitalization:

He had more time to bond with his family. He said that it was a nice feeling to know that
your family is so supportive to him. He learned to appreciate the beauty of having a family that
gives you strength and support no matter what.

SEXUALITY-REPRODUCTIVE PATTERN
According to him, he doesn’t think of the things like having a girlfriend and getting
married yet. He is still young for such matters.
COPING-STRESS TOLERANCE PATTERN
Before hospitalization:
He does not fully identify his situations having stress but he always tell her
parents when something is wrong.
During hospitalization:
He shares his problems to his family. He verbalizes his feelings.
VALUE-BELIEF PATTERN

He is a Roman Catholic devotee. He always goes with his family every Sunday to
go to mass. He was taught by his family to believe and have fear to GOD. They usually believe
in quack doctors.