I.

Introduction
Dengue fever is an acute febrile infectious disease, caused by all four serotypes (1, 2, 3 or 4) of a virus from genus Flavivirus, called dengue virus. Its the most prevalent flavivirus infection of humans, with a worldwide distribution in the tropics and warm areas of the temperate zone corresponding to that of the principal vector, Aedesaegypti. When simultaneous or sequential introduction of two or more serotypes occurs in the same area, there may be an increased number of cases with worse clinical presentation (dengue hemorrhagic fever). The term hemorrhagic is imprecise, because what characterizes this form of the disease is not the presence of hemorrhagic manifestations, but the abrupt increase of capillary permeability, with diffuse capillary leakage of plasma, hemoconcentration and, in some cases, with nonhemorrhagic hypovolemic shock (dengue shock syndrome). Incubation period: 3 - 6 days; some cases may reach 15 days. Dengue Fever: Symptoms begin with the abrupt onset of high fever, severe malaise, headache, retro-orbital pain, myalgia (lumbosacral pain, also involving legs), frequently accompanied by sore throat, nausea, vomiting, epygastric pain and diarrhea. In children, sore throat and abdominal pain are predominant. Defervescence occurs between days 3 and 8, usually followed by minor hemorrhagic phenomena (petechiae, purpura, epistaxis) and the onset of a maculopapular or morbilliform, sometimes pruritic rash on the trunk , with a centrifugal spread involving limbs, face, palms and soles. Some cases may advance with severe gastrointestinal bleeding and shock. Thus, the presence of hemorrhagic manifestations is not exclusively for dengue hemorrhagic fever. Dengue Hemorrhagic Fever (DHF): The early phase of illness is indistinguishable from dengue fever. After 2 - 5 days, however (defervescence period), a few cases in the first infection, in contrast with a significant number of cases after reinfection by another serotype may present with thrombocytopenia (< 100.000 /mm3) and hemoconcetration, the first usually preceeding the second. Hemorrhagic manifestations may or may not occur; the spleen is not palpable, but hepatic enlargement and tenderness is a sign of bad prognosis. Other manifestations include pleural effusion and hypoalbuminemia, encephalopathy with normal cerebrospinal fluid. Diffuse cappilary leakage of plasma is responsible for the hemoconcentration. In the presence of hemoconcentration and thrombocytopenia, the pacientis considered to be seized by dengue hemorrhagic fever and classified according to the following World Health Organization classification:

Grade I - thrombocytopenia + hemoconcentration. Absence of spontaneous bleeding. Grade II - thrombocytopenia + hemoconcentration.Presence of spontaneous bleeding. Grade III - thrombocytopenia + hemoconcentration. Hemodynamic instability: filiform pulse, narrowing of the pulse pressure (< 20 mmHg), cold extremities, mentalconffusion. Grade IV - thrombocytopenia + hemoconcentration. Declared shock, patient pulseless and with arterial blood pressure = 0 mmHg (dengue shock syndrome - DSS). The case-fatality of DHF/DSS is 10% or higher if untreated. With supportive treatment, fewer than 1% of such cases succumb. Recovery is rapid and without sequelae.

Diagnostic Test: Torniquet test y y y Inflate the blood pressure cuff on the upper arm to a point midway between the systolic and diastolic pressure for 5 mins. Release cuff and make an imaginary 2.5 cm square or 1 inch square just bellow the cuff, at the antecubitalfossa. Count the number of petichae inside the box. A test is positive when 20 or more petichae per square are observed.

Last August 11, 2010, I encountered a patient with such kind of disease. This patient has became my topic for this case study.

II. Objectives:
y y y y This case study aims to identify and determine the general health problems and needs of a patient with a Dengue Hemorrhagic Fever. This case study aims to promote health and medical understanding about Dengue Hemorrhagic Fever. This case study will help me understand the disease process of dengue fever. This study will help me orient myself the appropriate nursing interventions in managing Dengue Hemorrhagic Fever.

III. Patients Profile

Name Age Gender Address Date of Birth Occupation Nationality Civil Status Religion

: : : : : : : : :

Patient 1 20 years old Female Boni, Mandaluyong City January 21, 1990 N/A Filipino Single Catholic Fever August 8, 2010 Rizal Medical Center

Chief Complaint : Date Admitted : Hospital :

IV. Nursing History:

Three days prior to admission the patient had fever and lost her appetite. According to the mother of the patient during the first day of the fever the patient took Paracetamol. On the third day the patient still had the symptoms. The patient now consult the physician and was ordered to perform CBC test and torniquet test and was determined to be suffering from dengue. The patient then was admitted to Rizal Medical Center on August 15, 2010.

Past Medical History: According to the guardian of the patient, the patient had not yet experienced serious health problems other than fever, colds and cough. She had no previous hospitalization

V. Physical Examination

Date Assessed: August 11, 2010 General Assessment: Conscious and coherent Initial vital signs: T=36.2c RR=20 BP=110/80 PR=70

Area Assessed Findings skin w/ petichae on arms Color Moisture Texture Turgor Nail beds Capillary refill Eyes Visual acuity Eyebrows Eyelashes Eyelids Ears Hearing acuity Nose Comes back within 2-3 seconds Skin normal moisture Smooth and soft Skin snaps back immediately Pale

Evaluation Due to +torniquet test Normal Normal Normal Due to decreased blood flow Normal Normal Normal Normal Normal Normal Normal Normal

PERRLA Symmetrical Evenly distributed Same color of skin and blinks 2o times per minute Free of lesions, discharge and inflammation Client normally responds when asked Smooth, symmetrical, and w/o discharge

Neurology Level of Fully Conscious Consciousness Behavior and Expressess feelings when asked and Appearance in certain situations
VI-VII Anatomy Physiology And Pathophysiology

Normal Normal

Blood
Blood is considered the essence of life because the uncontrolled loss of it can result to death. Blood is a type of connective tissue, consisting of cell fragments surrounded by a liquid matix which circulates through the heart and blood vesseles. The cells and cell fragments are formed elements and the liquid is plasma. Blood makes about 8% of total weight of the body.

Functions of blood:
 transports gases, nutrients, waste products and hormones  involves in regulation of homeostasis and maintenance of PH, body temperature, fluid balance and electrolyte levels  protects against diseases and blood loss

Formed Elements: Erythrocytes (RBC)

Transport oxygen and carbon dioxide

Leukocyte (WBC) >Neutrophil

>Basophil Phagocytizes microorganism Release histamine, which promotes inflammation, and heparin w/c prevents clot formation Release chemical that reduce inflammation, attacks certain worm parasites Produces antibodies and other chemicals responsible for destroying microorganism Phagocytic cell in the blood leaves the circulatory systemand become macrophage w/c phagocytises bacteria, dead cells, cell fragments and debris within tissue

>Eosinophil

>Lympocytes >Monocyte

Platelet
Forms platelet plugs, release chemicals necessary for blood clotting.

Dengue fever, a contagious disease transmitted by the Aedesaegypti mosquito, infects between 50 million and 100 million people worldwide each year. Also known as breakbone or

dandy fever, dengue fever is found in the tropical and subtropical regions of the world. Exposure to the flavivirus that causes dengue fever results in one of three pathophysiologies: dengue fever, the more severe dengue hemorrhagic fever (DHF) or dengue shock syndrome. Transmission of Dengue Fever Dengue fever is transmitted only through an infected mosquito or by contact with the blood of someone who is actively infected with one of the four viruses responsible for the fever. Infection with one of these viruses generally provides immunity from dengue fever for as much as a year after the illness. A small minority of cases of dengue fever develop into severe forms of the fever, DHF or dengue shock syndrome, which require hospitalization. Dengue Haemorrhagic Fever (DHF) Clinical description Possibly more frequent in children and young adults Similar onset as Dengue Fever Complications usually start when fever subsides Facial flush Epigastric and abdominal pain Hepatomegaly Haemorrhagic tendencies Petechiae, Bruises, Hematuria, Hematemesis, Epistaxis, Melena/Blood in stools, Gingival bleeding Positive tourniquet test Haematology laboratory tests Platelet count < 100,000/mm3 Elevated haematocrit (hemoconcentration) > 20% the average value for the age

VIII. Medical Management

No specific treatment of dengue is available. Early institution of supportive treatment (fluids replacement and correction of electrolyte imbalances) is the key to management of patients with dengue in all its forms, since high fever, anorexia, vomiting and cappilary leakage result in some degree of dehidration. A. Criteria For Home Observation: y y y All cases of dengue fever with no need of intravascular fluids replacement; Patients regarded as Grade I capable of receiving oral fluids replacement therapy (OFRT); Patients regarded as Grade II capable of receiving OFRT and without important bleedings.

B. Criteria For Short-Duration Admission In Hospital (12 - 24 hours): y y y y y All cases of dengue fever that need intravascular fluids replacement; Patients regarded as Grade I without response to OFRT; Patients regarded as Grade II without response to OFRT; Patients regarded as Grade I or II with hepatic tenderness; All patients regarded as Grade III.

C. Criteria For Long-Duration Admission In Hospital (> 24 hours): y y Patients with no response to fluids replacement therapy after short-duration admission; Patients regarded as Grade I or II with predisposing factors to develop severe forms of presentation (asthma, alergies, diabetes mellitus, chronic obstructive pulmonary diseases ...) Patients regarded as Grade II or III with important bleedings; All patients regarded as Grade IV.

y y

Intensive monitoring of vital signs and markers of hemoconcentration, replacement of intravascular volume with lactated Ringers solution or isotonic saline , correction of metabolic acidosis, and O2 therapy is life-saving in patients with DSS. Once the patient is stabilized and capillary leakage stops and resorption of extravasated fluid begins, care must be taken not to induce pulmonary edema with continued intravenous fluid administration.

IX.

Laboratory Exams

Laboratory Findings: >Total White Blood Cells Count: In case of dengue, this test will reveal leukopenia. The presence of leukocytosis and neutrophilia excludes the possibility of dengue and bacterial infections (leptospirosis, meningoencephalitis, septicemy, pielonephritis etc.) must be considered. >Thrombocytopenia (< 100.000 /mm3): Total platelets count must be obtained in every patient with symptoms suggestive of dengue for three or more days of presentation. Leptospirosis, measles, rubella, meningococcemia and septicemy may also course with thrombocytopenia. >Hematocrit (micro-hematocrit): According to the definition of DHF, its necessary the presence of hemoconcentration (hematocrit elevated by > 20%); when its not possible to know the previous value of hematocrit, we must regard as significantly elevated the results > 45%.

Lab Report: Date: August 11, 2010

Parameter
White Blood Cells Hemoglobin Hematocrit Segmenters Lymphocytes Platelet Count

Normal Findings
5-19 x 10^g/l M: 13.0-18.0 g/dL 39-54 % 0.60-0.70 0.20-0.30 150-450 x 10^g/dL

Actual Findings
5 x 10^g/l 10 g/dL 30 % 0.68 0.32 18 x 10^g/dL

Lab Report: Date: August 12, 2010

Parameter
White Blood Cells Hemoglobin Hematocrit Segmenters Lymphocytes Platelet Count

Normal Findings
5-19 x 10^g/l M: 13.0-18.0 g/dL 39-54 % 0.60-0.70 0.20-0.30 150-450 x 10^g/dL

Actual Findings
5 x 10^g/l 10 g/dL 30 % 0.68 0.32 33 x 10^g/dL

X. Drug Study:
Paracetamol Dosage: 250 mg/5ml q4 RTC Classification:Nonpioid Analgesics & Antipyretics Indication: Mild pain or fever Action: Produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat regulating center. Adverse Reactions: y Hematologic: Hemolytic Anemia, Neutropenia, Leukopenia, Panyctopenia y Hepatic: Jaundice y Metabolic: Hypoglycemia y Skin: Rash, Urticaria Contraindications: y Contraindicated in pt. hypersensitive to drug y Use cautiously in pt. with long term alcohol use because therapeutic doses cause hepatotoxicity in these patients y Nursing Considerations: y ALERT: Many OTC and prescription products contain acetaminophen; be aware of this when calculating daily dose y Use liquid for for children and patients who have difficulty in swallowing y In children do not exceed five doses in 24 hours y Patient Teaching: y Tell parents to consult prescriber before giving drug to children younger than age 2

y y

Advice pt.or parents that drug is only for short term use; urge them to consult prescriber if giving to children for longer than 5 days or adults for longer than 10 days ALERT: Warn patient that high doses or unsupervised long term use can cause liver damage. Excessive alcohol use may increase the risk of liver damage.

Amoxicillin Dosage: 375mg TID Antibiotic

Classification:

Indication: Infections due to susceptible strains; helicobacter pylori infections in combination with other agents; post exposure prophylaxis against bacillusantharicis; Chlamydia trochomatis in pregnancy Action: Bactericidal Inhibits synthesis of bacterial cell wall, causing death

Adverse Reactions: y CNS Lethargy, hallucinations, seizures y G.I Glossitis, Stomatitis, gastritis, sore mouth, furry tongue, nausea, vomiting, diarrhea (bloody), enterocolitis, pseudomembranous colitis, nonspecific hepatitis y GU nephritis y Hematologic Rash, fever, wheezing, anaphylaxis y Others Superinfections: oral and rectal monoliasis, vaginitis Contraindications: Contraindicated with allergy to cephalosporins or penicillins, or other allergens Use cautiously with renal disorders and lactation Nursing considerations: y Culture infected area prior to treatment; reculture area if response is not expected y Give in oral preparations only; amoxicillin is not affected by food y Continue theraphy for at least 2 days after sign of infection have disappeared; continuation for 10 full days is recommended y Use corticosteroids or antihistamine for skin reactions Patient Teachings: y Take this drug around the clock y Take the full course of theraphy; do not stop because you feel better y This antibiotic is specific for this problem and should not be used to self treat the other infections

XI. Nursing Care Plan

Assessment Subjective: dumudugoangilongnganak ko as verbalized by the mother Objective: Weakness and irritability Restlessness V/s taken and recorded as follows T:38 PR:55 RR:20 BP:110/80

Diagnosis Risk for hemorrhag e related to altered clotting factor

Planning After 1 hour of nursing intervention s, the client will be able to demonstrate behaviors that reduce the risk for bleeding

Intervention Assess for signs of G.I. bleeding. Check for secretions. Observe color and consistency of stools or vomitus Observe for presence of petechiae, eccymosis, bleeding from one more sites Monitor pulse and blood pressure

Rationale The G.I. tract is the most usual source of bleeding of its mucosal fragility

Evaluation After 1 hour of nursing intervention s, the client was able to demostrate behaviors that reduce the risk for bleeding

May develop because of altered clotting factor

Note changes in mentation and level of consciousne ss

An increase in pulse and decrease in blood pressure can indicate loss of circulating blood volume Changes may indicate cerebral perfusion secondary to hypovolemia, hypoxemia Indicators of aneamia,activ e bleeding or impending complications

Monitor HB and Hct and clotting factore