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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 vomiting3. 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 Illness1. 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 f lushed
d. Positive tourniquet test
e. Anorexia, vomiting, myalgia
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f. 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 Herman’s sign known as the pathognomonic sto the disease.
g. Generalized or abdominal pain
h. Hemorrhagic manifestation like positive tourniquet test, purpura, epixtasis, and gum bleeding
maybe present.
2. Circulatory phase
a. There is a fall of temperature accompanied by profound circulatory changes on the 3rd
to 5th
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 levelh. 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
the 3rd
day, weakness, weight loss and abdominal pain. The mother decided to bring her son to SLH
because she saw her son’s nose bleeding.
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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.
c. 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.
d. 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.
e. Immunization
- According to the patient mother her son has a complete immunization.
f. Physical examination:
- The patient vomit 5x before arriving in the hospital. Has headache, loss appetite, weak, loss
weight, and abdominal pain is present.
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 pos ition in trendelenberg to provide
greater volume to the head part.
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III. PATHOGENESIS AND PATHOLOGY
1. 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.
2. Within few days, viremia occurs, lasting until 4th
or 5th
day onset of symptoms.
3. Evidence indicates that macrophages are the principal site of replication.
4. At the site of petechial rash, non-specific changes are noted which include endothelial swelling,
perivascular edema, and extravasation of blood.
5. There is marked increase in vascular permeability, hypotension, hemoconcentration, thrombocytopenia,
with increased platelet agglutinability and or moderate disseminated intravascular coagulation.
6. The most serious resulting from increased permeability of the vascular endothelium and loss of plasma
from the intravascular space.
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PATHOPHYSIOLOGY:
THOPHYSIOLOGY:Pedisposing
Geographical area- tropical islands in the
Pacific (Philippines) and Asia.
Precipitating
Environmental conditions (open spaces with water pots, and
plants)
Immunocompromise
Mosquito carrying dengue virus
Soldier
Sweaty skin
Aedes aegypt (dengue virus carrier). 8-12 days
of viral replication on mosquitos’ salivary
Bite from mosquito (Portal of Entry in the skin)
Allowing dengue virus to be inoculated
towards the circulation/blood (incubation
Period: 3-14 days)
Redness & itchiness in
the area
Virus disseminated rapidly into the blood and
stimulate WBC’s 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%)
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
Diagnostic:
Hematology:
Decreased Monocytes: 4%
(8-14%)
Decreased Neutrophils:
49% (50-70%)
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Entry to
the bon
Entry to the
spleen, and
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.
Dengue
Signs/ symptoms:
Febrile : 38.6C
Diaphoresis, warm skin,
flushed: headache of 3/10
pain scale; whitish spots; body
weakness
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
ThrombocytopeniaHepatosplenomegaly
Signs/ Symptoms:
Red sclera in both eyes
Petechiae
Signs/ symptoms:
Abdominal pain with 5/10
pain scale as verbalized
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Diagnostics:
Ultrasound minimal
hepatosplenomegaly
Blood Chemistry:
SGOT: 558.0
U/L(Up to 46)
Diagnostic:
Hematology:
Decreased platelet:
68 00 cumm
Dengue Hemorrhagic
Increase number and size of the pores in the capillaries wh
leads to a leakage of fluid from the blood to the the
interstitial fluid (capillary leakage) of the different
Signs/ symptoms:
+1 Bipedal edema: weak
bound in a pulse
Recovery
Complications:
Metabolic acidosis
Hyperkalemia
Tissue anorexia
Hemorrhage into the CNS
Uterine bleeding may occur
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IV. LABORATORY EXAMINATION:
DATE: January 26, 2012 January 30, 2012 NORMAL VALUES
WBC 3.55 7.98 4.8 – 10.8
RBC 4.57 3.88 M: 4.5 – 5.9
HEMOGLOBIN 124 107.2 M: 140 -175
HEMATOCRIT .392 .331 .414 - .504PLATELET 110 96 150 - 400
V. DRUG STUDY:
Brand name Classificati
on
Action Indication Contraindicatio
n
Side effect Nursing
Responsibilities
Paracetamol Analgesic,
muscle
relaxant
Decrease fever
by inhibiting
the side
effects of
pyrogens onthe
hypothalamic
heat
regulating
centers and by
a
hypothalamic
action leading
to sweating
and
vasodilation.
Relieves pain
by inhibitingprostaglandin
synthesis at
the CNS but
does not have
anti-
inflammatory
act on
beacause of its
minimal side
effect of
peripheral
prostaglandinsynthesis.
Relief to
mild to
moderate
pain
treatment of fever.
Hypersensitivity
intolerance to
tartazine
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
Advice patient
to avoid taking
more than one
product
containingparacetamol at
one time; as
this may cause
toxicity if taken
concurrently.
Advise patient
to avoid
alcohol; acute
poisoning with
liver damage
may result;
acute toxicityincludes
symptoms at
nausea,
vomiting, and
abdominal pain;
physician
should be
notified
immediately.
Teach the
patient torecognize signs
of chronic
overdose;
bleeding,
bruising,
malaise, fever,
sore throat.
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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 Diagnosis Planning Intervention Rationale Evaluation
Subjective:
“ Pauwi na kami
ng anak ko ano
ano ba mga
pede nyang
kainin pag uwi
namin?”
Objective:
AlertConscious
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
Readiness to
enhance
Nutrition
After 30 minutes
of health
teaching the
patient
significant
others will able
to express
knowledge of
healthy food
and fluid choiceto enhance
nutrition.
Assess eating
patterns and
food/ fluid
choices in
relationship to
any health risks
factor and
health goal.
Verify that agerelated and
developmental
needs are met.
Encourage
client’s
beneficial eating
pattern ( eg.
Following
dietary
program).
Discuss use of
nutritional
supplements,
OTC/ herbal
products.
Help to identify
specific
strengths and
weakness that
can be address.
These factorsare 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
After 30 mins.
Of health
teaching the
patients
significant
others are able
to respond or
express
knowledge of
healthy foodand fluid choice
to enhance
nutrition.
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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
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