ANATOMY AND PHYSIOLOGY

Blood has always fascinated humans, and

historically there has been much speculation about
its function. Blood was considered the “essence of
life” because the uncontrolled loss of it can result
in death. Blood is pumped by the heart through
the blood vessels, which extend throughout the
body. Blood helps to maintain homeostasis on
several ways: 1. transport of gases, nutrients and waste products, 2.
transport of processed molecules, 3. transport of regulatory molecules, 4.
regulation of pH and osmosis, 5. maintenance of body temperature, 6.
protection against foreign substances and 7. clot formation.
Blood is a type of connective tissue that consists of cell and cell
fragments are the formed elements, and the liquid is the plasma. The formed
elements account for slightly less than half and plasma accounts for slightly
more than half the total blood volume. The total blood volume in the average
adult is about 4-5L in females and 5-6L in males. Blood makes up about 8% of
total body weight.
Plasma is a pale yellow fluid that consists of about 91% water; 7%
proteins and 2% other substances such as ions, nutrients, gases and waste
products. Plasma proteins include albumin (maintains osmotic pressure),
globulins (antibodies and complement which are part of the immune system.
Some globulins are clotting factors which are necessary for the formation of
blood clots.) and fibrinogen (activation of clotting factors results in the
conversion of fibrinogen into fibrin—a threadlike protein that forms blood
clots. Serum is plasma without the clotting factors.
Formed elements consist of red blood cells (RBCs) or erythrocytes
(about 95%), the remaining 5% of the volume of the formed elements
consists of white blood cells (WBCs) or leukocytes and cell fragments called
platelets or thrombocytes. Red blood cells are 700 times more numerous
than white blood cells and 17 times more numerous than platelets.
Production of Formed Elements
The process of blood cell productiion is called hematopoiesis. In
fetus, hematopoiesis occurs in several tissues such as the liver, thymus
gland, spleen, lymph nodes, snd red bone marrow, but some white
blood cells are produced in the lymphatic tissues. All formed elements
of blood are derived from a single population of cells called stem cells
or hemocytoblasts. These stem cells differentiate to give rise to
different cell lines, each of which ends with the formation of particular
type of formed element. The development of each cell line is regulated
by specific growth factor. That is, the type of formed elements are
produced are determined by the growth factors.

Red Blood Cells or Erythrocytes

Normal RBCs are disk-shaped cells with edges that are thicker
than the center of the cell. The biconcave shape increases the surface
area of the red blood cell compared with a flat disck of the same size.
The greater surface area makes it easier for gases to move into and
out of the RBC. In addition, the RBC can bend or fold around its thin
center, decreasing its size and enabling it to pass more easily through
small blood vessels. The main component of the RBC is the pigmented
protein hemoglobin which accounts for about a third of the cell's
volume and is responsible for its color. RBCs transport oxygen from the
lungs to the various tissues of the body and to assist in the transport of
carbon dioxide from the tissues to the lungs.

White Blood Cells or Leukocytes

WBCs are spherical cells that lack hemoglobin. They are larger
than the RBCs and each has a nucleus. Although white blood cells are
components of the blood, the blood serves primarily as a means to
transport these cells to other tissues of the body. Two functions of the
white blood cells are 1. to protect the body against invading
microorganisms and 2. to remove dead cells an debris from the tissues
by phagocytosis. There are two types of WBCs the granulocytes which
contains cytoplasmic granules and there are three types of
granulocytes: a.) neutrophils are small phagocytic cells b.) basophils
promote inflammation and c.) eosinophils that reduce inflammation.
The other types of WBC are the agranulocytes that have very small
granules on which there are two types: a.) lymphocytes are involved in
the antibody production and other immune system respomses; b.)
monocytes become macrophages that ingest microorganisms and
cellular debris.

Platelets or Thrombocytes
Platelets are the minute fragments
of the cells, each consisting of a
small amount of cytoplasm
surrounded by a cell membrane.
They are produced in the red bone
marrow from megakaryocytes which are large cells. Small fragments of
these cells break off and enter the blood as platelets, which play an
important role in preventing blood loss. This prevention is
accomplished in two ways: 1. The formation of the platelet plugs which
seal holes in small vessels, and 2. The formation of clots, which help
seal off larger wounds in the vessels.
Platelet Plug is an accumulation of platelets that can seal up a
small break in a blood vessel. Platelet plug formation is very important
in maintaining the integrity of the circulatory system because small
tears can occur in the smaller vessels and capillaries many times each
day, and platelet plug formation quickly closes them. People who lack
the normal number of platelets tend to develop numerous small
haemorrhages in their skin and internal organs.
 The formation of a platelet plug
can be described as a series of steps, but
in actuality many of these steps occur at
the same time. (figure) Platelet adhesion
results in platelets sticking to collagen
exposed by blood vessel damage. Most
platelet adhesion is mediated through
von Willebrand factor, which is a protein
produced and secreted by blood vessel endothelial cells. Von
Willebrand factors forms a bridge between collagen and platelets by
binding to platelet surface receptors and collagen. After platelets
adhere to collagen, they become activated, change shape, and release
chemicals. In the platelet release reaction, platelets release chemicals
such as ADP and thromboxane. ADP and thromboxane binds to their
respective receptors on the surfaces of platelets, resulting in the
activation of the platelets. These activated platelets also releases ADP
and thromboxanes, which activates more platelets. Thus, a cascade of
chemical release activates more platelets. As platelets become
activated they express surface receptors called fibrinogen receptors,
which can bind to fibrinogen, a plasma protein. In platelet aggregation,
fibrinogen forms bridges between the fibrinogen receptors of
numerous platelets resulting in the formation of platelet plug.

Blood Clotting
Blood vessel constriction and platelet plugs alone are not
sufficient to close large tears or cuts in blood vessels. When a blood
vessel is severely damaged, blood clotting or coagulation results in the
formation of a clot. A clot is a network of threadlike protein fibers,
called fibrin that traps blood cells, platelets, and fluid.
The formation of a blood clot depends in a number of proteins
found within the plasma called clotting factors. Normally the clotting
factors are inactive and do not cause clotting. Following injury,
however, the clotting factors are activated to produce a clot. This is a
complex process involving many chemical reactions, but can be
summarized in three main stages:
1. The chemical reactions can be started in two ways:
a.) The contact of inactive clotting factors with exposed
connective tissue can result in their activation; b.)
chemicals such as thromboplastin, released from injured
tissues can cause activation of clotting factors. After the
initial clotting factors are activated, they in turn activate
other clotting factors. A series of reactions results in
which each clotting factor activates the next in the series
until the clotting factor prothrombinase is formed.
2. Prothrombinase acts on an inactive clotting factor called
prothrombin to convert it to its active form called thrombin.
Thrombin converts the inactive clotting factor fibrinogen into its
active form fibrin, a threadlike protein. A clot is a network of fibrin that
traps blood cells, platelets and fluids. At each step of the clotting
process, each clotting factors activates many additional clotting
factors. Consequently, a large quantity of clotting factor is activated,
resulting in the formation of a clot.
Most clotting factors are manufactured in the liver and many of
them require vitamin K for their synthesis. In addition, many of the
chemical reactions of clot formation require Ca2+ and the chemicals
released from platelets. Low levels of vitamin K, low levels of Ca2+,
low numbers of platelets, or reduced synthesis of clotting factors
because of liver dysfunvtion can seriously impair the blood-clotting
process.
Control of Clot Formation
Without control, clotting would spread from the point of its
initiation throughout the entire circulatory system. The blood contains
several anticoagulants, which prevent clotting factors from forming
clots. Anithrombin and heparin, for example, inactivate thrombin.
Without thrombin, fibrinogen is not converted to fibrin, and no clot
forms. Normally there are enough anticoagulants in the blood to
prevent clot formation. At an injury site, however, the activation of
clotting factor is very rapid. Enough clotting factors are activated so
that the anticoagulants can no longer prevent a clot from forming.
Away from the injury site there are enough anticoagulants to prevent
clot formation from spreading.

THE PATIENT’S ILLNESS (Book-Based)

A. Synthesis of the Disease
1. Definition of the Disease
Dengue fever is a type of arbovirus, short for arthropod-borne
virus, caused by one of the four closely related virus serotypes of the
genus Flavavirus—the dengue virus.The virus that causes dengue fever
is carried by Aedes aegypti mosquitoes, and is transmitted to humans
through their bite. An organism that carries a disease, without actually
developing the disease, is called a vector. It is also called as break
bone or dandy fever because of the bone/ joint pain and the way the
patient seems to be walking on his toes as joint pain affects the client's
toes.
The dengue virus causes the blood vessels to swell and leak,
creating small purple colored spots on the skin, called petechiae. The
skin may appear bruised in areas where the bleeding is worse.
Bleeding into the stomach causes severe abdominal pains and
vomiting of a black, grainy substance that looks like coffee grounds.
This severe bleeding, called hemorrhaging, occurs when the blood runs
out of clotting factors. The damaged blood vessels eventually become
so large that they are unable to supply the needed blood flow and the
oxygen it carries to the body's tissues. This causes the body to go into
shock, and can damage major organs such as the heart and kidneys.
Severe cases of dengue fever are called dengue hemorrhagic fever
(DHF) or dengue shock syndrome (DSS).
The body produces antibodies, which are disease-fighting cells,
that protect the patient who has had dengue fever from being
reinfected for around one year. However, more severe cases of dengue
fever often occur in patients who have already had the virus, then are
reinfected at a later time. Because the immune system recognizes the
virus, it overreacts, causing more severe symptoms. Most people who
have had dengue fever are more likely to have recurring similar viral
infections over the years.
Aedes Aegypti a.k.a tiger mosquito, a common household
mosquito, has the following characteristics, which can be better
remembered through the acronym DLSU: D-day bitting (2 hrs after
sunrise and 2 hrs before sunset), L-low flying, S-stagnant but clear
water and U-urban areas. Only female aedes aegypti mosquitoes which
have gray wings and white stripes are capable of bitting and
transmitting the virus. Susceptibility and risk factors to this virus are
very much important to know because these can alert us if we are at
risk of acquiring the virus. Some of which are: all persons are
susceptible, both sexes are equally affected, age group predominantly
affected are the preschool and school age peak age affectected 4-9
years old, more prevalent in urban communities and frequent in rainy
season. Hygiene and cleanliness in the environment are one of the
strongest defense that we can do against dengue.

2. Predisposing/Precipitating Factors
A. MODIFIABLE FACTORS
1. Environmental
Environmental factors such as artificial containers commonly
found in and around homes. Containers used for storage of water are
important in the increasing in population of mosquitoes in close
proximity to human dwellings. The vector is usually prevalent in urban
and suburban areas. In case of the patient lives in urban and suburban
areas there is a increase in possibility of acquiring the virus infection.

2. Lifestyle
One of the factors is increased in air travel, which is an ideal
mechanism of transferring the virus between population centers of the
world. Those people who acquire the disease are those travelers
visiting tropical areas. They become ill when they return home, which
is resulting in constant movement of dengue viruses.
 The female Aedes Aegypti usually bites during daytime, with
limited flying movements, breeds in clear stagnant water and
prevalent in urban and suburban areas. The patient usually plays
during daytime making him to be exposed with the virus and become
infected.
3. Socio- Economic Status
The low socio economic status plays a role in health- wellness
because this affects the family’s ability to give nutritious foods to
every member of the family. There is somehow relation in taking
nutritious feed and immune system since taking these foods
strengthens the immune system.

B. NON MODIFIABLE
1. Age
Worldwide, children younger than 15 years of age are the ones
commonly affected by the dengue virus.
2. Race
Even the race is not specific, the disease’s distribution is
determined geographically. There were fewer cases being reported in
black population than in other races. Most cases of dengue introduced
into United States came from American and Asian tropics, reflecting
the increased in number of persons travelling to and from those areas.

3. Sex
There is no predilection known. But there were fewer cases of
DHF that has been reported in men.
4. Season
Aedes Aegypti is commonly found in tropical and subtropical
countries. Philippines is a tropical country which has 3 major season:
cold (December to February), summer (March-May), and rainy season
(June to November). During rainy season the prevalence of DHF is high
due to accumulated rainwater that increases for mosquitoes’ breeding
places. The patient was diagnosed with DHF on the month of October
on which reported cases of DHF were extensive.

Signs and Symptoms With Rationale

Grade 1
1. Fever
Fever is normal response of the body towards an invading
microorganism (dengue virus). It results from the irritation of the
hypothalamus by chemical mediators (pyrogens and prostaglandin)
causing increased thermoregulatory set point in the hypothalamus.
2. Body pains
Body pain like epigastric pain and joint pain is cause by the
release of chemical mediator prostaglandin that causes the irritation of
the nociceptors causing pain perception.
3. Malaise
Since fever increases the body temperature and basal
metabolism, the body tends to utilize more energy to meet the
increased metabolic rate thus using the reserved or stored energy
resulting in body weakness

4. Anorexia
It has a relationship between malaise, which causes inadequate
food intake. It is also brought about by the alteration in taste sensation
that leads to decrease in appetite.
5. Nausea and Vomiting
This is due to the irritation of the medulla oblongata, which is the
vomiting center of the body.
6. Thrombocytopenia
 Dengue virus adheres to the platelet surface, which then
damages it. Platelets becomes injured and removed by the
reticuloendothelial cells of the spleen. Platelet destruction is greater
that platelet production hence reducing the circulating thrombocytes.
7. Petechiae Rash
The rashes appear after the Tourniquet Test in early stage of
dengue. This results from decreased circulating platelet cells and
increased capillary fragility.

Grade 2
1. Spontaneous Bleeding
The bleeding such as purpuric lesions, epistaxis, gum bleeding ,
GI bleeding, etc. results from the decrease circulating thrombocytes,
that enables the body to stop minute capillary bleeding causing
spontaneous bleeding.

Grade 3
1. Hemoconcentration
This is brought about by the increased capillary permeability that
allows some substances ( e.g plasma) to seep out of the capillary and
goes to the interstitial spaces. This results in decreased blood plasma
hence decreasing the circulating blood volume.
2. Cold and Clammy Skin
As a compensatory mechanism of the body in circulating the
volume of blood, peripheral blood vessels constrict to divert more
blood to the vital organs for perfusion. This condition may cause a
decrease surface temperature that results in cold clammy skin.
3. Decrease Blood Pressure
Plasma is the one of the main components of the blood. Plasma
leakage tends to decrease circulating blood volume. The blood volume
is directly proportion to the blood pressure thus as the blood volume
decreases, the blood pressure as well.
4. Rapid and weak pulse
This condition is the body’s compensatory mechanism. Because
blood volume declines, this means that the circulation is also
decreased. In Order to deliver adequate nutrients, oxygen and remove
waste product, especially to the vital organs, the heart will pump
harder and faster but with less stroke volume, which result in rapid
weak pulse.
5. Mental Confusion
Mental confusion is on the latter part of DHF 3 that precedes
shock. This results from decreased cerebral perfusion that causes the
alteration in perception, which is manifested by lethargy at first and
then restlessness.

Grade 4
1. Shock
Is the most critical stage of DHF. This is the end result of severe
plasma leakage, decreased circulating blood and decreased blood
pressure.

Health Promotion and Preventive Aspects of the Disease

Dengue fever, like other arbovirus infections, must run its
course. Treatment is focused on medications to lower fever and reduce
pain, fluids to prevent dehydration, and bed rest. Blood transfusions
are given in cases of severe blood loss, and oxygen must be given to
patients with dengue shock syndrome (DSS). Almost all patients with
dengue fever have a complete recovery. Those with DSS have a good
prognosis if they receive immediate medical treatment.
Supportive and Symptomatic treatment should be provided
• for fever, give paracetamol to muscle pains. For headache, give
 analgesic. DON"T give ASPIRIN.
• Rapid replacement of body fluids is the most important treatmet
• Includes intensive monitoring and follow-up
• Give ORESOL to replace fluid as in moderate dehydration at 75
mlk/kg in 4-6 hours or up to 2-3L in adults. Continue ORESOL
intake until patient's condition improves.
How to prepare ORESOL
• For 1 liter of water

▪ 1 liter pre-boiled waterborne

▪ 8 tsp sugar
▪ 1 tsp salt
▪ 1tsp baking soda
• For 1 glass

▪ 240ml/1cup preboiled water

▪ 2 tsp sugar
▪ ¼ tsp sugar
▪ ¼ baking soda
>mix ingredients but remember to make a new one after 24 hours
Methods of prevention and control
• Cover water drums and water pails at all times to prevent mosquitoes
from breeding.
• Replace water in flower vases once a week.
• Clean all water containers once a week. Scrub the sides well to remove
eggs of mosquitoes sticking to the sides.
• Clean gutters of leaves and debris so that rain water will not collect as
breeding places of mosquitoes.
• Old tires used as roof support should be punctured or cut to avoid
accumulation of water.
• Collect and dispose all unusable tin cans, jars, bottles and other items
that can collect and hold water.
• Fumigation would only drive away mosquitoes but would not clean the
 breeding grounds so it's not a good and effective way of preventing
dengue.
1. Eliminate vector by:
a. Changing water and scrubbing sides of lower vases once a week.
b. Destroy breeding places of mosquito by cleaning surroundings.
c. Proper disposal of rubber tires, empty bottles and cans.
d. Keep water containers covered.
2. Avoid too many hanging clothes inside the house.
3. Residual spraying with insecticides.
Prevention of Mosquito Bites
• Use mosquito nets during nights -mosquito nets with permethrine
solution are better.
• Wear bright and light color clothing, as mosquitoes are attracted to
dark clothing.
• Wear long sleeved clothes and long pants.

• Wear boots and socks and if necessary tuck the pants into the socks

• Avoid outdoor activities during dawn or dusk when these mosquitoes

are most active
• Avoid strong perfumes as they attract mosquitoes.
• Use mosquito repellent spray or lotion.

THE PATIENT’S ILLNESS (Patient-Based)

Non-Modifiable risk factors
1. Antibody for dengue virus
DHF may be caused by the four closely related virus
serotypes. The patient did not experience to have dengue infection
before. This made him susceptible to dengue infection since his body
has not yet developed antibody against strains of dengue virus. Since
being infected to one virus of serotypes of dengue make immunity to
that serotype for life, the patient can have more than one dengue
infection.
2. Age
 DHF may inflict people from all age groups, though it is more
common among children.
3. Sex
There is no preference known. DHF inflicts both male and
female. The patient is male.
4. Season
The patient lives in the Philippines which is a tropical country.
This characteristic contributes to the incidence of DHF especially
during the rainy season when rainwater easily accumulates in
particular areas which makes for good breeding places for mosquitoes.

Modifiable Risk Factors

1.Lifestyle
The patient went swimming with his family at a public pool.
He spent the whole day swimming and having fun. The next day, he
developed fever which was the beginning of his DHF. His mother also
mentioned that the pool was surrounded by plants which contributed
to the presence of mosquitoes.

Signs and Symptoms

The patient manifested the following:
Grade 1
• Fever, abdominal pain, and weakness
These are attributed to the release of prostaglandin and other cell
injury/ inflammatory mediators secondary to the release of viral
anaphylatoxins.
• Abnormal WBC count
The presence of inflammation and cell injury leads to abnormal
test result. The presence of virus triggered the stimulation of body’s
defense mechanism which includes the release of WBC component of
the blood.
• Petechiae
The client had reddish rashes on his lower extremities,
specifically his legs. This is related to the presence of weak capillaries
secondary to the activation of kinins which affect the vascular
permeability. Capillaries are fragile blood vessels. Increase in vascular
permeability causes increased pressure towards the capillary.

Grade 2
The patient manifested bleeding, specifically epistaxis.

*The patient did not manifest grade 3 and 4 DHF*