Eiselle G.

San Diego Case Presentation: DHF II with warning sign

I. INTRODUCTION: A. Dengue Fever Dengue fever is an acute febrile disease caused by infection with one of the serotypes of dengue virus which is transmitted by mosquito genus Aedes egyptis. B. Etiology 1. Flaviviruses 1, 2, 3, 4, a family of Togaviridae are small viruses that contain single strand RNA. 2. Arboviruses group B C. Incidence 1. Age dengue fever may occur at any stage, but is more common among children and peak between 4 to 9 years old. 2. Sex both sexes can be affected. 3. Season it is more frequent during the rainy season. 4. Location dengue fever is more prevalent in urban communities.

D. Clinical Manifestations: A. Dengue fever 1. Prodromal symptoms characterized by: a. Malaise and anorexia up to 12 hours b. Fever and chills accompanied by several frontal headache, ocular pain, myalgia with severe backache, and arthralgia. 2. Nausea and vomiting 3. Fever is non-remitting and persist for 3 days to 7 days. 4. Rash is more prominent on the extremities and the trunk. It may involve the face in some isolated cases. 5. Petechiae usually appears near the end of the febrile period and most common on the lower extremities. B. Dengue Hemorrhagic Fever (DHF) This severe form of dengue virus infection manifested by fever, hemorrhagic diathesis, hepatomegaly and hypovolemic shock. Phases of the Illness 1. Initial febrile phase lasting from two to three days. a. Fever (39-40 degree C) accompanied by headache b. Febrile convulsion may appear c. Palms and sole are usually flushed d. Positive tourniquet test e. Anorexia, vomiting, myalgia

f.

g. h.

Maculopapular or petechial rash maybe present that usually starts in the distal portain of the extremities (sparing the axilla and chest), the skin appears purple with blanched areas with varied sizes, the Hermans sign known as the pathognomonic sto the disease. Generalized or abdominal pain Hemorrhagic manifestation like positive tourniquet test, purpura, epixtasis, and gum bleeding maybe present.

2.

Circulatory phase rd th a. There is a fall of temperature accompanied by profound circulatory changes on the 3 to 5 day b. Patient becomes restless, with cool clammy skin. c. Cyanosis is present d. Profound thrombocytopenia accompanies the onset of the shock e. Bleeding diathesis may become more severe with GIT hemorrhage. f. Shock may occur due to loss of plasma from the intravascular spaces and hemoconcentration with markedly elevated hematocrit is present. g. Pulse is rapid and weak; pulse pressure becomes narrow and blood pressure may drop to an unobtainable level h. Untreated shock may result to comma, metabolic acidosis and death may occur within 2 days. i. With effective therapy, recovery may follow in 2 to 3 days. Classification According to Severity ( Halstead & Nimmanitya) Grade I There is fever accompanied with non-specific constitutional symptoms and the only hemorrhagic manifestation is positive (+) tourniquet test. Grade II All signs of Grade I plus spontaneous bleeding from the nose, gums, GIT are present. Grade III There is presence of circulatory failure as manifested by weak pulse, narrow pulse pressure, hypotension, cold clammy skin and restlessness. Grade IV There is profound shock, undetectable blood pressure and pulse.

II. PATIENT PROFILE A. Patient data Patient is 6 years old male suffering from fever ( 40 degree C) for 3 days, headache, vomit for 5 times on rd the 3 day, weakness, weight loss and abdominal pain. The mother decided to bring her son to SLH because she saw her sons nose bleeding.

B.

Nursing history a. Chief complaint: nose bleed b. Past health history According to the mother her son was not always sick like other children. His son only have fever, and flu even when his son is still baby. Personal and social history According to the patient mother his son was in grade 1 studying in tayuman and have twin brother. The mother does not work and his husband is working as an electrician. His son plays a lot in school and at home. They are residing in Tayuman with there relatives in 1 compound. His son is not picky on choosing food to eat even it is vegetable or fish. Developmental history The patient is 6 years old. He answered congruent to my question with eye contact. Currently grade 1 studying in Tayuman. His age is appropriate to his grade level in school. The patient can read, write and name the object around him. Immunization According to the patient mother her son has a complete immunization. Physical examination: The patient vomit 5x before arriving in the hospital. Has headache, loss appetite, weak, loss weight, and abdominal pain is present.

c.

d.

e.

f.

C.

Course in the ward: Vital signs every 4 hours Keep patient at rest during bleeding episodes. Analgesic drugs other than aspirin is require for the relief oh headache, ocular pain, and myalgia. For the initial phase intravenous infusion is given for prevention of dehydration and plasma replacement. For nose bleed, patient is positioned with trunk elevated and applying ice bag to the bridge of nose and to the forehead is advised. For the restoration of blood volume the patient is position in trendelenberg to provide greater volume to the head part.

III. PATHOGENESIS AND PATHOLOGY 1. 2. 3. 4. 5. 6. Infectious virus is deposited in the skin by the vector and initial replication occurs at the site of the infection and in local lymphatic tissues. th th Within few days, viremia occurs, lasting until 4 or 5 day onset of symptoms. Evidence indicates that macrophages are the principal site of replication. At the site of petechial rash, non-specific changes are noted which include endothelial swelling, perivascular edema, and extravasation of blood. There is marked increase in vascular permeability, hypotension, hemoconcentration, thrombocytopenia, with increased platelet agglutinability and or moderate disseminated intravascular coagulation. The most serious resulting from increased permeability of the vascular endothelium and loss of plasma from the intravascular space.

PATHOPHYSIOLOGY: THOPHYSIOLOGY:

Pedisposing

Precipitating
Environmental conditions (open spaces with water pots, and plants) Immunocompromise Mosquito carrying dengue virus Soldier Sweaty skin

Geographical area- tropical islands in the Pacific (Philippines) and Asia.

Aedes aegypt (dengue virus carrier). 8-12 days of viral replication on mosquitos salivary glands

Redness & itchiness in the area

Bite from mosquito (Portal of Entry in the skin)

Allowing dengue virus to be inoculated towards the circulation/blood (incubation Period: 3-14 days)

Virus disseminated rapidly into the blood and stimulate WBCs including B lymphocytes that produces and secretes Immunoglibulins (antibodies), and monocvtes/macrophages, neutrophils.

Diagnostics: Hermatology: Increased WBC: 12, 900/cumm (5, 000 10, 000/cumm) Increased Lymphocytes: 49% (20-40%)

Diagnostic: Hematology: Decreased Monocytes: 4% (8-14%) Decreased Neutrophils: 49% (50-70%)

Antibodies attach to the viral antiges, and then monocytes/macrophages will perform phatocytosis through Fc receptor (FcR) within the cells and dengue virus replicates in the cells

Entry to the spleen, and

Entry to the bone marrow

Recognition of dengue viral antigen on infected monocyte

Release of cytokines which consist of vasoactive agents such as interleukins , tumor necrosis factor, urokinase and platelet activating factors which stimulates WBCs and pyrogen release.

Signs/ symptoms: Febrile : 38.6C Diaphoresis, warm skin, flushed: headache of 3/10 pain scale; whitish spots; body weakness

Dengue

Virus ultimately targets liver and spleen parenchymal cells where infection produces

Cellular direct destruction and infection of red bone marrow precursor cells as well as immunological shortened platelet

Hepatosplenomegaly
Signs/ symptoms: Abdominal pain with 5/10 pain scale as verbalized

Thrombocytopenia

Signs/ Symptoms: Red sclera in both eyes Petechiae

Diagnostics: Ultrasound minimal hepatosplenomegaly Blood Chemistry: SGOT: 558.0 U/L(Up to 46)

Diagnostic: Hematology: Decreased platelet: 68,00/cumm

Dengue Hemorrhagic

Signs/ symptoms: +1 Bipedal edema: weak bound in a pulse

Increase number and size of the pores in the capillaries which leads to a leakage of fluid from the blood to the the interstitial fluid (capillary leakage) of the different

Recovery

Complications: Metabolic acidosis Hyperkalemia Tissue anorexia Hemorrhage into the CNS Uterine bleeding may occur myocarditis

IV. LABORATORY EXAMINATION: DATE: WBC RBC HEMOGLOBIN HEMATOCRIT PLATELET January 26, 2012 3.55 4.57 124 .392 110 January 30, 2012 7.98 3.88 107.2 .331 96 NORMAL VALUES 4.8 10.8 M: 4.5 5.9 M: 140 -175 .414 - .504 150 - 400

V. DRUG STUDY: Brand name Paracetamol Classificati on Analgesic, muscle relaxant Action Decrease fever by inhibiting the side effects of pyrogens on the hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilation. Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not have antiinflammatory act on beacause of its minimal side effect of peripheral prostaglandin synthesis. Indication Relief to mild to moderate pain treatmen t of fever. Contraindicatio n Hypersensitivity intolerance to tartazine Side effect Stimulation, drowsiness, nausea, vomiting, abdominal pain, hepatotoxicity, hepatic seizure (overdose), renal failure ( high prolonged doses), leukopenia, neutropenia, hemolytic anemia, thrombocytopeni a, rash, urticarial, hypersensitivity, cyanosis, anemia, neutropenia, jaundice, pancytopenia, CNS stimulation, delirium followed by vascular collapse, convulsion, coma, death Nursing Responsibilities Advice patient to avoid taking more than one product containing paracetamol at one time; as this may cause toxicity if taken concurrently. Advise patient to avoid alcohol; acute poisoning with liver damage may result; acute toxicity includes symptoms at nausea, vomiting, and abdominal pain; physician should be notified immediately. Teach the patient to recognize signs of chronic overdose; bleeding, bruising, malaise, fever, sore throat.

Inform the patient that urine may become dark brown as a result of phenacelin (metabolite of acetaminophen ) Tell patient to notify prescribe for pain or fever lasting for more than 3 days.

VI. NURSING CARE PLAN Assessment Subjective: Pauwi na kami ng anak ko ano ano ba mga pede nyang kainin pag uwi namin? Objective: Alert Conscious Self assisted Consume adequate food Dried skin Thin Vital signs as follows: T: 36.2 degree C P: 90 bpm R: 14 bpm BP: 100/70 mm Hg Diagnosis Readiness to enhance Nutrition Planning After 30 minutes of health teaching the patient significant others will able to express knowledge of healthy food and fluid choice to enhance nutrition. Intervention Assess eating patterns and food/ fluid choices in relationship to any health risks factor and health goal. Verify that age related and developmental needs are met. Rationale Help to identify specific strengths and weakness that can be address. Evaluation After 30 mins. Of health teaching the patients significant others are able to respond or express knowledge of healthy food and fluid choice to enhance nutrition.

These factors are constantly present throughout life span, although differing for each age group. Positive feedback promotes continuation of healthy lifestyle habits and new behavior. Confusion may exist regarding the need for/ use of these products in

Encourage clients beneficial eating pattern ( eg. Following dietary program). Discuss use of nutritional supplements, OTC/ herbal products.

balanced dietary regimen.

VII. Discharge Planning Discuss about a mosquito free environment to avoid further transmission of infection. Eliminate the vector by: Changing water and scrubbing sides of flower vases once a week Destroy the breeding place of mosquitos by cleaning the surroundings Keeping the water containers covered Avoiding too many hanging clothes inside the house Discuss about eating nutritios food and fluids. Follow up check up. Adequate rest Personal hygiene