CASE

PRESENTATION

Dengue Hemorrhagic Fever

Presented by:
Vernalin B. Terrado
Dengue Hemorrhagic Fever
General Objectives:
• The ultimate purpose of this study is to refresh
the learned concepts about dengue
hemorrhagic fever and to develop the
understanding on the particular disease in
accordance with further research and
presentation based on the patients situation.
Specific Objectives:
This case presentation seeks to provide different
information about the disease to be presented and
about the client being considered with the
following specific objectives:
• Give a brief introduction about Dengue
hemorrhagic fever together with its signs and
symptoms.
• Discuss the theoretical framework that is
related to the client’s condition.
• Present the client’s demographic data and
health history with its Gordon’s pattern of
functioning.
• Present the abnormal results of the Physical
Assessment made on the client.
• Present the different laboratory results or test
done to the client with its interpretation.
• Discuss the normal Anatomy and Physiology
of the Blood.
• Explain the Pathophysiology of Dengue
Hemorrhagic Fever
• Discuss the drugs prescribed to the client by a
Drug Study.
• Present an appropriate Nursing Care Plan for
the most prioritized problem.
• Give a Discharge Plan that the client may use
upon discharge to the hospital
Introduction:
Dengue hemorrhagic fever is an
acute febrile diseases found in
tropics.It is a complication of
Dengue fever with hemorrhages. It
is characterized by abnormal
vascular permeability,
hypovolemia and abnormal blood
clotting mechanism. The
Dengue virus type 1,2,3,4, along
with other arboviruse which are
chikungunya, O’ nyong-nyong,
west nile and flavi virus are
classified as the causative agents.
The vector responsible for the
transmission of the virus is the
domestic, day- biting mosquito
known as the Aedes aegypti.The
vector responsible for the
transmission of the virus is the
domestic, day-biting mosquito
known as the Aedes aegypti.
 Clinical manifestations according to its grade
are persistent high fever, complains of pain,
nausea and vomiting, and pathological
vascular changes which is classified as
Grade I, Grade II is persistence of signs and
symptoms of Grade I with bleeding while
Grade III has additional signs of circulatory
failure and Grade IV with signs and
symptoms of hypovolemic shock that can lead
to death.
Diagnostic test used to determine DHF are Rumpel
leads test otherwise known as Tourniquet test and
platelet count test that is shown in hematology
examination.Treatment is mainly symptomatic and
supportive.
Theoretical Framework:
Nightingale's core nursing
theory has an environmental
focus: It was her belief that the
environment is an alterable
medium that can be used to
improve the conditions of
Nature and encourage healing.
Ventilation, clean air, clean
water, control of noise,
provision for light, and
Adequate waste management
are just a some of the elements
She believed could be
Monitored and improved when
necessary.
 Nightingale’s theory addresses the prevention of
occurrences of Dengue Hemorrhagic Fever. In
facilitating proper environmental sanitation we can
achieve a surroundings with no presence of any vector
that cause its transmission as they can no longer exist if
the environment is not suited for their survival hence
decreasing the morbidity rate of Dengue in our country.
We should be knowledgeable on how to keep our
surroundings free from any breeding sites that could
serve as a reservoir for the mosquito. As a nurse we
should teach our clients how to do proper water storage
and environmental sanitation so as to prevent disease
occurrence and recurrence.
Comprehensive History:
Biographic Data:

• Name: E.D.B
• Date : 7-21-09
• Time of Admission 10:45 AM
• Unit/Room: Pedia isolation
room
• Address: Norzagaray,
Baliuag, Bulacan
• Age: 8 y/o
• Gender: Female
• Status: N/A
• Religion: Roman Catholic
• Citizenship: Filipino
• Birth date: February 25, 2001
• Birthplace: OLSJDM
• Attending Physician:
• Final Diagnosis: DHF III
• Working Diagnosis: DFS I
• Chief Complaint: Abdominal pain
with vomiting
Nursing History
Past Medical History
According to her mother the patient doesn’t
experience any illness before that they treat of as an
immediate concern aside from developing UTI when she
was 5 years old. The patient only experienced having
common cough and colds occasionally. She also
experiences fever before and it was relieved by over the
counter drugs and rest. Their family don’t seek
consultation for regular health check up. She hasn’t been
hospitalized and only seeks consultation to their
Baranggay Health center whenever any health problem
arises. She doesn’t also receive an immunization vaccine
for measles.
History of Present Illness:
Five days prior to admission the client suffers from
having a high fever with a temperature of 39. 4 degrees
celcius, Paracetamol was given for relief. After three
days the fever subsides and abdominal pain and
vomiting of brownish colored vomitus takes place which
prompted her hospitalization.

Upon admission the child have experienced gum

bleeding and have presence of petechiae over the face
and lower extremities accompanied by fatigue and loss
of appetite. Hematology examination shows low platelet
count with a value of 80 mm3.
During the interview session she has a fever and
experiences no bleeding at all. Her abdominal pain also ceases.
Family History:
According to the mother of the patient
They only have history of hypertension on her
mother side in their family while she doesn’t
have any knowledge about the health history
in the side of his husband.
They claim to have suffered from no
serious illness though they sometimes
experiences common illnesses within the
members of their family.
Activities of Daily Living
Gordon’s Functional Health
Patterns
a. Health Perception and Health
Management Pattern
The patient sees her
pattern of health as
normal as she suffered
from no serious illnesses
before. She manages her
health by following her
mothers instructions
such as sleeping early
and eating foods on
regular basis. She also
follows proper personal
hygiene for her to
become healthy.
b.Nutritional and Metabolic
Pattern
The patient usually eats
Vegetables because they
have many of it planted in
their backyard. She said that
her favorite food is junk
Foods especially chips and
Salty foods. She is also fond
of eating sweets such as
chocolates and candies. She
Usually drinks up to 6
glasses of water a day
including other beverages. She
is not taking any vitamin
Supplements.
The following is her 24hour diet recall.
Breakfast One (1) cup of rice, fried egg with
fried eggplant and a glass of chocolate
drink.

Lunch One (1) cup of rice, menudo and a

glass of water.

Dinner One (1) cup of rice, a slice of fried fish

a glass of water.
c. Elimination Pattern
She move her bowel
twice a day with the usual
color of light brown that
occasionally change
In accordance with her
Choices of foods. She also
urinates 4-5 times a day
which has light yellow
color.
d. Activity-Exercise Pattern
The usual activity
pattern of the patient
involves her activities of
daily living, going to school
and helping in light
household chores. Her
hobbies are watching TV
and reading story books
She spends most of her
time playing outside with
her cousins and friends.
 e. Sleep-Rest Pattern
The client doesn’t have
any difficulty in sleeping
pattern. She sleeps at
around 8 in the evening and
wake up early. She doesn’t
have the habit of sleeping at
daytime. She usually drinks
Milk before she goes to
Sleep and she usually
sleeps at about 10 hours
daily.
 f. Cognitive-Perceptual Pattern
The patient is able to
read and write. She is
currently in grade two in
elementary education
and portrays a sharp
memory when asked
about past experiences and
significant others. She also
has good eyesight
and has a normal
functioning for her
senses and perception.
g. Self-Perception and Self
Concept Pattern
She verbalizes
Satisfaction with her
abilities and talents. She
Also describe herself as a
Very jolly person though
she is sad during the
Interview because of her
Current condition. With the
help of her Mother she was
able to answer most of my
questions. She has good
body posture and was able
to maintain eye contact
upon interview.
h. Role-Relationships Pattern:
She is the youngest
among her siblings. She
helps the other family
members by doing and
following little tasks
whenever they ask her to
do so. The patient has a
good family relationship. She
state that she is happy with
them and they care and love
her so much. The significant
people in clients life is her
mother.
i. Sexuality-Reproductive Pattern
This pattern is not
asked because this is not
applicable to the patient
due to clients age.
 j. Coping-Stress Pattern:
As a child she also
deals with some of stressful
events everyday. When
she was in school her
teacher helps her with
her study and school
works. She manage her
problems with the help of
the significant others. Her
Status now being sick is one of
The greatest stressor for the
client and she was able to
cope up because of their aid.
k.Values-Belief Pattern:
The client is a catholic
and she usually goes to
church every Sunday
with her family. She state
that being polite to them and
Following elderly them is an
Important value for her. She
Usually prays at night before
she goes to sleep. She believed
That God is always with her
And would never leave her no
matter what happens..
V. Physical Assessment

BP: 100/90 mmhg PR: 78 bpm

Temperature: 38.6 degrees celcius RR: 18 bpm

BODY PARTS TECHNIQUE USED NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

A. SKIN Inspection, palpation Varies from light toDark brown in color-Indicates impaired skin
deep brown, from ruddycomplexion with someintegrity.
pink to light pink, frompresence of wounds and-Hyperthermia
yellow overtones toabrasions in the extremities
olive, generally uniformof the client. No nodes or
skin temperature. mass elevation can be
palpated.. Hot to touch and
flushing skin.

B. HAIR Inspection Thick, silky, resilient,Thick and sticky withImproper personal

free from infestation,presence of some lice. hygiene.
evenly distributed and
covers the whole scalp.

C. NAILS Inspection, Palpation Convex curvatureConvex curvature smoothAn indication of improper

smooth texture, highlytexture, highly vascular andhygiene.
vascular and pink,light pink to pale in color.
prompt return of pinkCapillary refill after 2-3 sec.
less than 3 seconds. Nails have deposition of dirt
in its tips and sides.
D. NECK REGION Inspection, palpation Symmetrical andSymmetrical and straight,Due to presence of
straight, no palpablewith palpable lymph nodes infection
lumps, and supple,
trachea is on midline of
neck, and spaces are
equal on both sides.

E. LUNGS Auscultation Symmetrical chestSymmetrical chestNot normal. Crackles

expansion, clear breathexpansion, Crackles soundsound is due to pleural
sounds. heard upon auscultation.effusion.
Dyspnea is not observed.

F. HEART Auscultation Normal rate, regularNo palpitation, no murmur Normal

rhythm, no murmur.

G. PERIPHERAL Palpation Symmetrical pulseSymmetrical pulse volume,Normal

volume, full pulsation. full pulsation.

H. BREAST Inspection, Palpation Round shape, slightlySymmetrical, with noNormal

unequal in size,protuberance elevation.
generally symmetrical,
no tenderness, masses,
nodules or nipple
discharge.
I. ABDOMEN Inspection, Auscultation,Uniform color,No scars seen uponNormal
Percussion, rounded symmetricalinspection. Uniform in
Palpation contour, audible bowelcolor, audible bowel
sounds, tenderness,sounds.
liver and bladder are
not palpable.

J. VAGINA Inspection No inflammation,No inflammation, swellingNormal

swelling or discharge. or discharge.

K. UPPER ANDInspection Equal size on bothEqual size on both sides ofNot normal
LOWER sides of the body,the body. An ongoing IVFPalpable lymph nodes
EXTREMITIES weakness on the lowerof D5LR hooked @ rightindicates infection.
and upper extremities. arm regulated at 35Wounds indicates
gtts/min. Lymph nodes inimpaired skin integrity.
the Axilla and groins are
palpable. Noticeable
presence of wounds on the
lower right extremity and
both forearm.
1. SKULL Inspection, Palpation Proportional to the sizeProportional to the size ofNormal
of the body, round withthe body with prominence in
prominences in thethe frontal and occipital
frontal and occipitalarea, symmetrical in all
area, symmetrical in allplaces.
places.

2. SCALP Inspection White, clean, free fromWhite, slightly oily, withoutImproper hygiene..
masses, lumps, scars,presence of masses, lumps,
and lesions, no areas ofscars, and lesions but with
tenderness presence of lice.

3. FACE Inspection Oblong or round orOblong shaped, symmetricalNormal

square or heart shaped,with no involuntary muscle
symmetrical, facialmovements. No facial
expression that isgrimace is observed.
dependent on the mood
or true feelings and no
involuntary muscle
movements.

4. EYES Inspection Parallel and evenlyParallel and evenly spaced,Normal

spaced symmetrical,pupils are bluish gray in
non-protruding, pinkcolor, equal in size.
palpebral conjunctiva
and pupils black in
color, equal in size,
round and constricts in
response to light.
5. NOSE Inspection Midline symmetricalMidline symmetrical andNormal
and patent, nopatent, no discharge.
discharge.

6. EARS Inspection Parallel symmetrical,Parallel symmetrical,Improper hygiene.

proportional to the sizeproportional to the size of
of the head, bean-the head, bean-shaped, skin
shaped, skin is sameis same color as the
color as the surroundingsurrounding color, clean
color, clean firmfirm cartilage. With
cartilage. presence of softened
cerumen.There is also a
presence of wound in the
pina of the right ear of the
client.

7. MOUTH Inspection Symmetrical, gumsSymmetrical, gums pinkishImproper dental care.

pinkish in color, lipsto dark in color, lips is also
margin is symmetrical,dark brown in color..margin
no lesion andis symmetrical, no lesion
tenderness, withoutand tenderness, .She have
involuntary movement. many dental cavities due to
junk foods.
HEMATOLOGY:
Date: July 21, 2009 Time: 6 Am
Blood Components Results Normal Values

Hemoglobin 142 120-150 g/L- F

140-170 g/L- M

Hematocrit 0.44 0.37-0.47 g/L - F

0.40-0.50 g/L - M

Platelet Count 80 150-350 microliter

WBC 13,400 5,000-10,000 microliter

 The result of hematology examination has
a normal hemoglobin count as well as the
hematocrit. On the other hand the platelet or
the thrombocyte is way below the normal
value which indicates thrombocytopenia
while the leukocytes or the white blood cell
increase which shows that there’s an
infection present.
ANATOMY and PHYSIOLOGY:
BLOOD

Blood- a connective tissue

composed of a liquid
extracellular matrix called
blood plasma that dissolves
and suspends various cells and
cell fragments.

1 - Formed elements:
• Red blood cells (or
erythrocytes)
• White blood cells (or
leucocytes)
• Platelets (or
thrombocytes)
2 - Plasma = water + dissolved
solutes
Characteristics of Blood:
• bright red
• dark red/purplish
• much more dense than pure water
• pH range from 7.35 to 7.45
• slightly warmer than body temperature
• typical volume in an adult is 5 liters
• 8% of body weight
Major Functions of Blood:
• Distribution & Transport
• Regulation (maintenance of homeostasis)
• Protection
Formed elements
RBC
• biconcave disk shape
• a hemoglobin carrier
• anucleate
• No mitochondria
• 120 lifespan
• erythropoietin is the
hormone that stimulates
RBC production
 Erythropoiesis

RBC enters the circulation

Blood pass through the lungs

And gas exchange occurs

Gas Exchange through tissues

RBC circulates for 120 days

WBC or Leukocytes:
• protection from
microbes, parasites,
toxins, cancer
• 1% of blood volume; 4-
11,000 per cubic mm
blood
• amoeboid motion
• chemotaxis
• leukocytosis
• leukopoiesis
• Colony stimulating
Factors and interleukins-
stimulates white blood
cell formation
Types of White Blood Cells
Platelets

• formed in the bone

marrow from cells called
megakaryocytes
• very small, 2-4 microns in
diameter
• approximately 250-
500,000 per cubic
millimeter
• essential for clotting of
damaged vasculature
• Thrombopoietin
stimulates the production
 damage to endothelium of vessel

Platelet platelets adhesion

Plug
Formation
Platelets release reaction

platelets aggregation
 Pathophysiology Poor environmental sanitation

Mosquito bites a susceptible host

Virus multiply in the bloodstream

Creates multiple lesion in the blood stream Increased phagocytic

activity

Increase Excessive Increase fever

capillary consumption vascular
fragility of platelets permeability

Hemorrhagic Thrombocytopenia Leakage of plasma

manifestations

Pleural Effusion
Drug study
•Ranitidine
•Paracetamol
Medication Action Indication Contraindication Side Effects Nursing
Responsibilities

Decreases fever by Hypersensitivity • drowsiness • Assess patients fever

Generic Name: inhibiting the Treatment of fever and • Nausea or pain:type of pain,
location , intensity,
Paracetamol effects of pyrogens pain. • Abdominal pain duration,
on the hypothalamic • Anemia temperature,
Brand Name: heat regulating • vomiting diaphoresis
centers. • Assess allergic
reactions:rash,
Dosage: urticaria, if these
occur, drug may
7-5 ml have to be
discontinued.
Route: • Check input and
output ratio
PO • Inform th patient that
urine may become
dark brown as a
result of phenacetin
• Teach patient to
recognize signs of
over dosage,
bleeding, brising.
 Medication Action Indication Contraindication Side Effects Nursing
Responsibilities

Inhibits histamine Used in Hypersensitivity. • Bradycardia • Assess potential for

Generic Name: at H2 receptor site management of History of acute • Headache interactions with
other pharmaceutical
Ranitidine in the gastric Various porphyria • Fatigue agents patient may
parietal cells, which Gastrointestinal • Dizzines be taking.
Brand Name: inhibits gastric acid disorders such as GI • Insomnia • Use caution in
Zantac secretion. hemorrhage. • Depression presence of renal and
hepatic impairment
• Do not take any new
Dosage: medication during
therapy without
20 mg consulting a
physician
• Take axactly as
Route: directed
TIV • Follow diet as
physician
Frequency: recommends
q8 • Report chest pain or
irregular heartbeats,
skin rash, CNS
change; unusual
persistent weakness
or lethargy,
yellowing of skin or
eyes.
Nursing Care Plan
•Hyperthermia
•Impaired Skin Integrity
 Cues Nursing Nursing objective Planning Nursing intervention Rationale Evaluation
diagnosis
Subjective Cues: After 3 >Formulate >Perform TSB Promotes heat After 3 hours of
“Mainit padin po Alterations in hours of Independent Continuously loss through Nursing
ang pakiramdam body Nursing plans to meet conduction and Intervention the
temperature Intervention the Your objective evaporation. clients
ko as verbalize by temperature is
related to To promote
the client.” clients in reducing surface cooling decreased into a
Objective Cues:
increase temperature will clients’ >Remove Excessive normal range
by evaporation
pyrogens in decrease into a 37.3 degrees
>Body temperature temperature Clothes and covers Prevent
the normal dehydration. celsius
of 38.6 degrees >Gather
bloodstream range(36.5-37.5
celcius Materials
>Hot, flushed skin. degrees celsius) needed in the >Promote To reduce
Scientific metabolic
>diaphoresis Explanation: Implementation Increase Fluid
demands
>Increased Body of the nursing intake
To promote
WBC(13,400 μL) temperature interventions. >Maintain bed rest. heat loss through
BP: 100/90 mmhg above normal >Plan strategies convection.
PR: 78 bpm range to educate >Provide Proper To reduce their
Temperature: 38.6 Significant others Ventilation anxiety and get
degrees celcius so that they can their cooperation
upon caring for
RR: 18bpm be
the client.
helpful in your >Educate
Nursing Significant Others
Intervention. Regarding Normal
Temperature and
Control measures
 Cues Nursing diagnosis Nursing objective Planning Nursing Rationale Evaluation
intervention

Subjective Cues: >Give For immediate

Antipyretics decrease in patients
body temperature.
Objective Cues: Medication
As ordered
BP: 100/90 mmhg
PR: 78 bpm
Temperature: 38.6
degrees celcius
RR: 18 bpm
 Cues Nursing Nursing objective Planning Nursing Rationale Evaluation
diagnosis intervention

Subjective Cues: After 3 days of >Plan Assessed skin. Establishes After 3-days
Impaired skin Nursing intervention Noted color, comparative baseline of nursing
“Makati po ang integrity related that will turgor, and providing
intervention intervention,
mga sugat ko sa sa to mechanical promote sensation. opportunity for
factors as the client will be wound Described and the client was
braso at binti” as
evidence by able to display healing in a measured timely intervention. able to
verbalized by the disruption of given span of wounds and
improvement in Display
client skin surface time. observed
wound healing as Improvement
>formulate changes
Objective Cues: evidenced by: ways on how Demonstrated Maintaining clean, in wound
>presence of Scientific
•Intact skin or to teach good skin dry skin provides a healing as
wounds in the Explanation
minimized significant hygiene, e.g., barrier to infection. Evidenced
lower right Alteration of the others in
presence of wash thoroughly Patting skin dry by:
extremity and both Epidermis proper caring and pat dry instead of rubbing •Minimized
wound..
because of of the carefully. reduces risk of
forearm. •Absence of presence of
external factors wounds. dermal trauma to
>pruritus Redness >Use wounds.
such as shearing fragile skin.
>warm to touch orerythema. methods to Instructed •Several
force Skin friction
wound surface. •Absence of improve skin family to caused by stiff or wounds have
>with watery integrity in an maintain clean, rough clothes leads
Purulent accessible anddry clothes, dried up.
discharge. discharge. to irritation of fragile •Minimized
easy way. preferably skin and increases
•Absence of cotton fabric risk for infection Erythema
itchiness. •Minimized
(any T-shirt).
itchiness
 Cues Nursing Nursing Planning Nursing intervention Rationale Evaluation
diagnosis objective

Subjective Cues: Emphasized Improved nutrition and

importance of hydration will improve
skin condition.
Objective Cues: Adequate nutrition

and fluid intake. Providing the family

BP: 100/90 mmhg
Demonstrated with alternative solution
PR: 78 bpm
to the family assists them in optimal
Temperature: 38.6 healing with less expensive
degrees celcius members on how to
RR: 18 bpm make a guava resources.
decoction to apply
to the wound as
Alternative
disinfectant. Long and rough nails
Instructed increase risk of skin
family to clip and damage.
file nails regularly.
Provided and Wound dressings protect
applied wound the wound and the
surrounding tissues.
dressings carefully.
DISCHARGE PLAN:
• Medicine – Paracetamol PRN.
-Don’t give aspirin and NSAIDs
• Exercise- Encourage patients to resume to her Activities of daily living
-perform range of motions and repetitive body movements for
promotion of optimum health.
• Therapy- Water Therapy
-Promotion of proper personal hygiene.
• Health teachings- Change water in vases on alternate days.
- cover water containers
- used mosquito repellant lotions..
-avoid places with stagnant waters.
• Out patient follow up care- Instruct the family members to
have a check-up after a week 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,
-Vitamin K rich foods such as green leafy
vegetables
-Vit C rich foods(guava and tomatoes and other
citrus fruits)
-Carbohydrates rich food (breads and rice)
• Spiritual- Encourage the patient to pray together with
the family to thank God for her wellness. Ask for
more guidance and protection to prevent the
recurrence of the disease among family members.