Chapter I

INTRODUCTION

Dengue Fever is caused by one of the four closely related, but antigenically distinct, virus
serotypes Dengue type 1, Dengue type 2, Dengue type 3, and Dengue type 4 of
the genus Flavi virus and Chikungunya virus. Infection with one of these serotype
provides immunity to only that serotype of life, to a person living in a Dengue-endemic
area can have more than one Dengue infection during their lifetime. Dengue fever through the
four different Dengue serotypes are maintained in the cycle which involves humans
and Aedes aegypti or Aedes albopictus mosquito through the transmission of the viruses
to humans by the bite of an infected mosquito. The mosquito becomes infected with the
Dengue virus when it bites a person who has Dengue and after a week it can
transmit the virus while biting a healthy person. Dengue cannot be
transmitted or directly spread from person to person. Aedes aegypti is the most
common aedes specie which is a domestic, day-biting mosquito that prefers to feed on humans.

I N T U B AT I O N P E R I O D : U n c e r t a i n . P r o b a b l y 6 - 1 0 d a y s

PERIOD OF COMMUNICABILITY: Unknown. Presumed to be on the 1st week of illness

when virus is still present in the blood

CLINICAL MANIFESTATIONS:

First 4 days:
 Febrile or invasive stage - starts abruptly as high fever, abdominal pain and headache;
later flushing which may be accompanied by vomiting, conjunctival infection and
epistaxis

4th to 7th day:

 Toxic or hemorrhagic stage - lowering of temperature, severe abdominal pain,vomiting
and frequent bleeding from GIT in the form of melena; unstable BP,narrow pulse
pressure and shock; death may occur; vasomotor collapse.

7th to 10th day:

 Convalescent or recovery stage - generalized flushing with intervening areas
of blanching appetite regained and blood pressure already stable

1
MODE OF TRANSMISSION:

Dengue viruses are transmitted to humans through the infective bites of female
Aedes mosquito. Mosquitoes generally acquire virus while feeding on the blood of an infected
person. After virus incubation of 8-10 days, an infected mosquito is capable, during
probing and blood feeding of transmitting the virus to susceptible individuals for the rest of its
life. Infected female mosquitoes may also transmit the virus to their offspring by transovarial (via
the eggs) transmission.
Humans are the main amplifying host of the virus. The virus circulates in the
blood of infected humans for two to seven days, at approximately the same time as they have
fever. Aedes mosquito may have acquired the virus when they fed on an individual during this
period. Dengue cannot be transmitted through person to person mode.

CLASSIFICATION:

1. Severe, frank type

 flushing, sudden high fever, severe hemorrhage, followed by sudden drop of temperature,
shock and terminating in recovery or death.


2. Moderate
 with high fever but less hemorrhage, no shock present.

3. Mild
 with slight fever, with or without petechial hemorrhage but epidemiologically related to
typical cases usually discovered in the course of invest or typical cases.

2
 Chapter II
Identification of the Case

A. Personal Information

Patient’s Initials: R.L.

Age: 13
Address: Brgy. Sanghay, Malalag, Davao Occidental
Religion: Pentecostal
Educational Background: High School 1st Year Level
Date Admitted: November 29, 2015
Time Admitted: 7:00 pm
Nationality: Filipino
Mother’s Name: Maxilinda Father’s Name: Morillo
Occupation: BHW Occupation: Carpenter
Chief complaint: Referred from local hospital due to low platelet
Final diagnosis: Dengue with warning signs.

3
B. Family Health History (Genogram)

F.L. M.L. L.B. M.B.

ALC BL, RA ALC DM
73 100 73 63

Father Mother
A&W A&W
43 41

J.A.L. J.L. J.L.

P2,A&W R.L.
P1,A&W A&W
23 13
19 17

Legend:

ALC – Alcoholic Female

DM – Diabetes mellitus
BL – Blindness Male
RA – Rheumatoid arthritis
Patient
P – Parity
A&W – Alive
Gray color – Deceased

The patient’s paternal grandfather died at the age of 73 due to unknown reasons. His
paternal grandmother is still alive at the age of 100 although she is suffering from blindness and
4
rheumatoid arthritis. Both maternal grandparents are still alive with the grandfather being an
alcoholic and the grandmother having diabetes mellitus. Patient R.L.’s parents are also alive and
well with no current diseases. The patient has four siblings with the eldest who gave birth to
twins at the age of 16. His second sister also gave birth via NSVD at the age of 18. His brother is
still alive and well.

C. Medical History

According to the mother of the patient, he hasn’t been admitted to the hospital before not
until when he was diagnosed with Dengue. During the past years, the patient only get sick with
occasional flu's, and they seek remedy by taking over-the-counter drugs or going to local faith
healers.

Patient completed his immunization at their local health center like BCG, DPT, OPV,
HEPA B and Measles.

On November 1, 2014, patient received anti-rabies vaccination for his dog bite. A month
prior to his hospital admission, patient had a minor motorcycle accident wherein he got his left
shoulder sprained.

On November 29, 2015, patient was referred from their local hospital to DSPH due to
low platelet count. He had a final diagnosis of dengue with warning signs.

D. History of present illness

On November 26, 2015 the patient experienced fever and complained of slight
discomfort. Two days after, his fever became worse at 39.1 oC in which his parents decided to
admit him in their local hospital wherein he was treated with paracetamol.
On November 29, 2015, their local hospital referred the patient to DSPH due to a platelet
count of 36. He was then admitted to the pediatric ward with an initial diagnosis of dengue fever
with warning signs. At 9:00 pm of that same day, his platelet count rose to 65. Afterwards, new
orders were made by the attending physician.

E. Socio-economic background

5
 Patient R.L. is now currently attending grade VI in Malita national high school. Since
he’s still a student, his parents relies on financially support. The patient’s mother works as a
barangay health worker with salary of Php 4,000 to Php 6,000 every month. His father earns
about Php 8,000 every 15 days as a carpenter. He has three siblings in the family with the eldest
23 years old and the youngest is him which is 13 years of age.

Chapter III
Anatomy and Physiology of the Blood

6
Blood facts

 Approximately 8% of an adult’s body weight is made up of blood.

 Females have around 4-5 litres, while males have around 5-6 litres. This difference is
mainly due to the differences in body size between men and women.
 Its mean temperature is 38 degrees Celcius.
 It has a pH of 7.35-7.45, making it slightly basic (less than 7 is considered acidic).
 Whole blood is about 4.5-5.5 times as viscous as water, indicating that it is more resistant
to flow than water.
 Blood in the arteries is a brighter red than blood in the veins because of the higher levels
of oxygen found in the arteries.

Functions of blood
Blood has three main functions: transport, protection and regulation.

Transport

Blood transports the following substances:

 Gases, namely oxygen (O2) and carbon dioxide (CO2), between the lungs and rest of the
body
 Nutrients from the digestive tract and storage sites to the rest of the body
 Waste products to be detoxified or removed by the liver and kidneys
 Hormones from the glands in which they are produced to their target cells
 Heat to the skin so as to help regulate body temperature

Protection

Blood has several roles in inflammation:

 Leukocytes, or white blood cells, destroy invading microorganisms and cancer cells
 Antibodies and other proteins destroy pathogenic substances
 Platelet factors initiate blood clotting and help minimise blood loss

Regulation

Blood helps regulate:

 pH by interacting with acids and bases

 Water balance by transferring water to and from tissues

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Composition of blood

Blood is classified as a connective tissue and consists of two main components:

1. Plasma, which is a clear extracellular fluid

2. Formed elements, which are made up of the blood cells and platelets

The formed elements are so named because they are enclosed in a plasma membrane and have a
definite structure and shape. All formed elements are cells except for the platelets, which are tiny
fragments of bone marrow cells.

Formed elements are:

 Erythrocytes, also known as red blood cells (RBCs)

 Leukocytes, also known as white blood cells (WBCs)
 Platelets

Leukocytes are further classified into two subcategories called granulocytes which
consist of neutrophils, eosinophils and basophils; and agranulocytes which consist of
lymphocytes and monocytes.

8
 The formed elements can be separated from plasma by centrifuge, where a blood sample
is spun for a few minutes in a tube to separate its components according to their densities. RBCs
are denser than plasma, and so become packed into the bottom of the tube to make up 45% of
total volume. This volume is known as the haematocrit. WBCs and platelets form a narrow
cream-coloured coat known as the buffy coat immediately above the RBCs. Finally, the plasma
makes up the top of the tube, which is a pale yellow colour and contains just under 55% of the
total volume.

Blood plasma

Blood plasma is a mixture of proteins, enzymes, nutrients, wastes, hormones and gases.
The specific composition and function of its components are as follows:

Proteins

These are the most abundant substance in plasma by weight and play a part in a variety of
roles including clotting, defence and transport. Collectively, they serve several functions:

 They are an important reserve supply of amino acids for cell nutrition.
 Plasma proteins also serve as carriers for other molecules. The proteins also help to keep
the blood slightly basic at a stable pH.
 The plasma proteins interact in specific ways to cause the blood to coagulate, which is
part of the body’s response to injury to the blood vessels (also known as vascular injury), and
helps protect against the loss of blood and invasion by foreign microorganisms and viruses.
 Plasma proteins govern the distribution of water between the blood and tissue fluid by
producing what is known as a colloid osmotic pressure.
There are three major categories of plasma proteins, and each individual type of proteins has its
own specific properties and functions in addition to their overall collective role:

1. Albumins, which are the smallest and most abundant plasma proteins. Albumin also
helps many substances dissolve in the plasma by binding to them, hence playing an important
role in plasma transport of substances such as drugs, hormones and fatty acids.
2. Globulins, which can be subdivided into three classes from smallest to largest in
molecular weight into alpha, beta and gamma globulins. The globulins include high
density lipoproteins (HDL), an alpha-1 globulin, and low density lipoproteins (LDL), a beta-1
globulin. HDL functions in lipid transport carrying fats to cells for use in energy metabolism,
membrane reconstruction and hormone function. LDL carries cholesterol and fats to tissues
for use in manufacturing steroid hormones and building cell membranes, but it also favours
the deposition of cholesterol in arterial walls and thus appears to play a role in disease of the

9
 blood vessels and heart. HDL and LDL therefore play important parts in the regulation of
cholesterol and hence have a large impact on cardiovascular disease.
3. Fibrinogen, which is a soluble precursor of a sticky protein called fibrin, which forms
the framework of blood clot. Fibrin plays a key role in coagulation of blood, which is
discussed later in this article under Platelets.

Amino acids

These are formed from the break down of tissue proteins or from the digestion of digested
proteins.

Nitrogenous waste

Being toxic end products of the break down of substances in the body, these are usually cleared
from the bloodstream and are excreted by the kidneys at a rate that balances their production.

Nutrients

Those absorbed by the digestive tract are transported in the blood plasma. These include glucose,
amino acids, fats, cholesterol, phospholipids, vitamins and minerals.

Gases

Some oxygen and carbon dioxide are transported by plasma. Plasma also contains a substantial
amount of dissolved nitrogen.

Electrolytes

The most abundant of these are sodium ions, which account for more of the blood’s osmolarity
than any other solute.

Red blood cells

Red blood cells (RBCs), also known as erythrocytes, have two main functions:

1. To pick up oxygen from the lungs and deliver it to tissues elsewhere

2. To pick up carbon dioxide from other tissues and unload it in the lungs
An erythrocyte is a disc-shaped cell with a thick rim and a thin sunken centre. The plasma
membrane of a mature RBC has glycoproteins and glycolipids that determine a person’s blood
type. On its inner surface are two proteins called spectrin and actin that give the membrane

10
resilience and durability. This allows the RBCs to stretch, bend and fold as they squeeze through
small blood vessels, and to spring back to their original shape as they pass through larger vessels.
The cytoplasm of a RBC consists mainly of a 33% solution of haemoglobin (Hb), which gives
RBCs their red colour. Haemoglobin carries most of the oxygen and some of the carbon dioxide
transported by the blood.

Circulating erythrocytes live for about 120 days. As a RBC ages, its membrane grows
increasingly fragile.

White blood cells

White blood cells (WBCs) are also known as leukocytes. They can be divided into
granulocytes and agranulocytes. The former have cytoplasms that contain organelles that appear
as coloured granules through light microscopy, hence their name. Granulocytes consist of
neutrophils, eosinophils and basophils. In contrast, agranulocytes do not contain granules. They
consist of lymphocytes and monocytes.

Granulocytes

1. Neutrophils: These contain very fine cytoplasmic granules that can be seen under a light
microscope. They play roles in the destruction of bacteria and the release of chemicals that
kill or inhibit the growth of bacteria.
2. Eosinophils: These have large granules and a prominent nucleus that is divided into two
lobes. They function in the destruction of allergens and inflammatory chemicals, and release
enzymes that disable parasites.
3. Basophils: They have a pale nucleus that is usually hidden by granules. They secrete
histamine which increases tissue blood flow via dilating the blood vessels, and also secrete
heparin which is an anticoagulant that promotes mobility of other WBCs by preventing
clotting.

Agranulocytes

1. Lymphocytes: These are usually classified as small, medium or large. Medium and large
lymphocytes are generally seen mainly in fibrous connective tissue and only occasionally in
the circulation bloodstream. Lymphocytes function in destroying cancer cells, cells infected
by viruses, and foreign invading cells. In addition, they present antigens to activate other cells

11
 of the immune system. They also coordinate the actions of other immune cells, secrete
antibodies and serve in immune memory.
2. Monocytes: They are the largest of the formed elements. Their cytoplasm tends to be
abundant and relatively clear. They function in differentiating into macrophages, which are
large phagocytic cells, and digest pathogens, dead neutrophils, and the debris of dead cells.
Like lymphocytes, they also present antigens to activate other immune cells.

Platelets

Platelets are small fragments of bone marrow cells and are therefore not really classified as cells
themselves.

Platelets have the following functions:

1. Secrete vasoconstrictors which constrict blood vessels, causing vascular spasms in

broken blood vessels
2. Form temporary platelet plugs to stop bleeding
3. Secrete procoagulants (clotting factors) to promote blood clotting
4. Dissolve blood clots when they are no longer needed
5. Digest and destroy bacteria
6. Secrete chemicals that attract neutrophils and monocytes to sites of inflammation
7. Secrete growth factors to maintain the linings of blood vessels
The first three functions listed above refer to important haemostatic mechanisms in which
platelets play a role in during bleeding: vascular spasms, platelet plug formation and blood
clotting (coagulation).

Vascular spasm

This is a prompt constriction of the broken blood vessel and is the most immediate
protection against blood loss. Injury stimulates pain receptors. Some of these receptors directly
innervate nearby blood vessels and cause them to constrict. After a few minutes, other
mechanisms take over. Injury to the smooth muscle of the blood vessel itself causes a longer-
lasting vasoconstriction where platelets release a chemical vasoconstrictor called serotonin. This
maintains vascular spasm long enough for the other haemostatic mechanisms to come into play.

Platelet plug formation

Under normal conditions, platelets do not usually adhere to the wall of undamaged blood
vessels, since the vessel lining tends to be smooth and coated with a platelet repellent. When a

12
vessel is broken, platelets put out long spiny extensions to adhere to the vessel wall as well as to
other platelets. These extensions then contract and draw the walls of the vessel together. The
mass of platelets formed is known as a platelet plug, and can reduce or stop minor bleeding.

Coagulation

This is the last and most effective defence against bleeding. During bleeding, it is
important for the blood to clot quickly to minimise blood loss, but it is equally important for
blood not to clot in undamaged vessels. Coagulation is a very complex process aimed at clotting
the blood at appropriate amounts. The objective of coagulation is to convert plasma protein
fibrinogen into fibrin, which is a sticky protein that adheres to the walls of a vessel. Blood cells
and platelets become stuck to fibrin, and the resulting mass helps to seal the break in the blood
vessel. The forming of fibrin is what makes coagulation so complicated, as it involved numerous
chemicals reactions and many coagulation factors.

Production of blood

Haemopoiesis

Haemopoiesis is the production of the formed elements of blood. Haemopoietic tissues

refer to the tissues that produce blood. The earliest haemopoietic tissue to develop is the yolk
sac, which also functions in the transfer of yolk nutrients of the embryo. In the foetus, blood cells
are produced by the bone marrow, liver, spleen and thymus. This changes during and after birth.
The liver stops producing blood cells around the time of birth, while the spleen stops producing
them soon after birth but continues to produce lymphocytes for life. From infancy onwards, all
formed elements are produced in the red bone marrow. Lymphocytes are additionally produced
in lymphoid tissues and organs widely distributed in the body, including the thymus, tonsils,
lymph nodes, spleen and patches of lymphoid tissues in the intestine.

Erythropoesis

Erythropoiesis refers specifically to the production of erythrocytes or red blood cells

(RBCs). These are formed through the following sequence of cell transformations:

13
 The proerythroblast has receptors for the hormone erythropoietin (EPO). Once EPO
receptors are in place, the cell is committed to exclusively producing RBCs. The erythroblasts
then multiply and synthesise haemoglobin (Hb), which is a red oxygen transport protein. The
nucleus from the erythroblasts is then discarded, giving rise to cells named reticulocytes. The
overall transformation from haemocytoblast to reticulocytes involves a reduction in cell size, an
increase in cell number, the synthesis of haemoglobin, and the loss of the cell nucleus. These
reticulocytes leave the bone marrow and enter the bloodstream where they mature into
erythrocytes when their endoplasmic reticulum disappears.

Leukopoiesis

Leukopoiesis refers to the production of leukocytes (WBCs). It begins when some types of
haemocytoblasts differentiate into three types of committed cells:
1. B progenitors, which are destined to become B lymphocytes
2. T progenitors, which become T lymphocytes
3. Granulocyte-macrophage colony-forming units, which become granulocytes and
monocytes
These cells have receptors for colony-stimulating factors (CSFs). Each CSF stimulates a different
WBC type to develop in response to specific needs. Mature lymphocytes and macrophages
secrete several types of CSFs in response to infections and other immune challenges. The red
bone marrow stores granulocytes and monocytes until they are needed in the bloodstream.
However, circulating leukocytes do not stay in the blood for very long. Granulocytes circulate
for 4-8 hours and then migrate into the tissues where they live for another 4-5 days. Monocytes
travel in the blood for 10-20 hours, then migrate into the tissues and transform into a variety of
macrophages which can live as long as a few years. Lymphocytes are responsible for long-tern
immunity and can survive from a few weeks to decades. They are continually recycled from
blood to tissue fluid to lymph and finally back to the blood.

14
Thrombopoiesis

Thrombopoiesis refers to the production of platelets in the blood, because platelets used
to be called thrombocytes. This starts when a haemocytoblast develops receptors for the hormone
thrombopoietin which is produced by the liver and kidneys. When these receptors are in place,
the haemocytoblast becomes a committed cell called a megakaryoblast. This replicates its DNA,
producing a large cell called a megakaryocyte, which breaks up into tiny fragments that enter the
bloodstream. About 25-40% of the platelets are stored in the spleen and released as needed. The
remainder circulate freely in the blood are live for about 10 days.

Chapter IV
Symptomatology

15
 Chapter V
Pathophysiology

16
17
 Chapter VI
Medical Management

Ideal
There are no specific antiviral drugs for dengue, however maintaining proper fluid balance is
important. Treatment depends on the symptoms. Those who are able to drink, are passing urine,
have no "warning signs" and are otherwise healthy can be managed at home with daily follow up
and oral rehydration therapy. Those who have other health problems, have "warning signs" or
who cannot manage regular follow up should be cared for in hospital. In those with severe
dengue care should be provided in an area where there is access to an intensive care unit.
Intravenous hydration, if required, is typically only needed for one or two days. The rate of
fluid administration is titrated to aurinary output of 0.5–1 mL/kg/h, stable vital signs and
normalization of hematocrit. The smallest amount of fluid required to achieve this is
recommended. Invasive medical procedures such as nasogastric intubation, intramuscular
injections and arterial punctures are avoided, in view of the bleeding risk.
Paracetamol (acetaminophen) is used for fever and discomfort while NSAIDs such
as ibuprofen and aspirin are avoided as they might aggravate the risk of bleeding.Blood
transfusion is initiated early in people presenting with unstable vital signs in the face of
a decreasing hematocrit, rather than waiting for the hemoglobin concentration to decrease to
some predetermined "transfusion trigger" level. Packed red blood cells or whole blood are
recommended, while platelets and fresh frozen plasma are usually not. There is not enough
evidence to determine if corticosteroids have a positive or negative effect in dengue fever.
During the recovery phase intravenous fluids are discontinued to prevent a state of fluid
overload. If fluid overload occurs and vital signs are stable, stopping further fluid may be all that
is needed. If a person is outside of the critical phase, a loop diuretic such as furosemide may be
used to eliminate excess fluid from the circulation. In Tamilnadu(India), Indian medicines such
as Papaya juice extract, Nilavembu and Malaivembu kudineer along with conventional medicine
are used for the control of Dengue under Vector Borne Disease Control Programme.

18
Actual/Doctor’s Order

November 29,2015 @ 1pm Justification/Rationale

Dr.Delos Reyes
>pls. admit >patient assessment requires admission.

> Measure pulse hourly and temperature and

>V/Sq4 ⁰ with BP blood pressure 4-hourly.

> require for patient with transfusion

reactions

> Your health care provider may order this

>DAT test:

>screen for high levels of sugars, proteins,

ketones and bacteria for possible bladder or
> CBC kidney infections, diabetes, and dehydration

>acidosis is commonly treated by

dialysis,burt severe cases may be treated
> UA with sodium bicarbonate.

>to verify the results

>hematocrit q8⁰

>follow-up Lab test

19
 Chapter VII
Laboratory Findings

Laboratory Findings
Complete Blood Count Nov. 30, 2015 AM
NORMAL
TEST RESULTS REMARKS
VALUES
WBC 1.5 x 109/L 4.0 – 10.0  Decrease due to inadequate
inflammatory response defense to
suppress infection and antibody
mediated immunity takes place.
LYMPH# 0.5 x 109L 0.8 – 4.0  Low lymphocytes count indicates that
the body is low on infection resistance.
 Decrease due to debilitating illness,
humoral immune response to take place.
MID# 0.2 x 109/L 0.1 – 1.5 within normal range
GRAN# 0.8 x 109/L 2.0 – 7  Dengue virus induces bone marrow
suppression thus bone marrow fails to
make enough granulocytes.
 Low granulocyte count can be caused
by viral infection
LYMPH% 32.0% 20.0 – 40.0 within normal range
MID% 12.8% 3.0 – 15.0 within normal range
GRAN% 55.2% 50.0 – 70.0 within normal range
HGB 139 g/L 120. – 160 within normal range
RBC 5.02 x 1012/L 4.00 – 5.50 within normal range
HCT 42.7% 40.0 – 54.0 within normal range
MCV 85.2fL 80.0 – 100.0 within normal range
MCH 27.6 pg 27.0 – 34.0 within normal range
MCHC 325g/L 320 – 360 within normal range
RDW-CV 13.1% 11.0 – 16.0 within normal range
RDW-SD 43.2fL 35.0 – 56.0 within normal range
PLT 65 x 109/L 100 – 300  Dengue virus induces bone marrow
suppression. Since bone marrow is the
manufacturing centre of blood cells its
suppression causes deficiency of blood
cells leading to low platelet count.
 When vascular endothelial cell that
infected with dengue virus gets
combined with platelets they tend to
destroy platelets.
 The antibodies that are produced after
infection of dengue virus can contribute
in destruction of platelets, thus lowering
the platelet count.
MPV 8.1fL 6.5 – 12.0 within normal range
PDW 16.6 9.0 – 17.0 within normal range

20
PCT 0.052% 0.108 – 0.282
 Decrease due to the presence of dengue
virus

 Low PCT levels indicate a minor

infection
HEMATOLOGY REPORT
Date: Nov. 29 2015, PM
Examination Desired: Plt, Hct

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS

Thrombocytes 150-400 x 103/mL 65
Fraction 0.42-0.47 vol % 0.35

HEMATOLOGY REPORT
Date: Nov. 30 2015, AM
Examination Desired: blood typing, Plt, Hct

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS

Thrombocytes 150-400 x 103/mL 72
Fraction 0.42-0.47 vol % 0.41
Blood group: A positive
HEMATOLOGY REPORT
Date: Nov. 30 2015, PM
Examination Desired: Plt, Hct

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS

Thrombocytes 150-400 x 103/mL 111
Fraction 0.42-0.47 vol % 0.39

HEMATOLOGY REPORT
Date: Dec. 01 2015, AM
Examination Desired: Plt, Hct

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS

Thrombocytes 150-400 x 103/mL 90
Fraction 0.42-0.47 vol % 0.37

HEMATOLOGY REPORT
Date: Dec. 01 2015, PM
Examination Desired: Plt, Hct

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS

Thrombocytes 150-400 x 103/mL 118
Fraction 0.42-0.47 vol % 0.40

21
 HEMATOLOGY REPORT
Date: Dec. 02 2015, AM
Examination Desired: Plt, Hct

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS

Thrombocytes 150-400 x 103/mL 130
Fraction 0.42-0.47 vol % 0.38

HEMATOLOGY REPORT
Date: Dec. 02 2015, PM
Examination Desired: Plt, Hct

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS

Thrombocytes 150-400 x 103/mL 159
Fraction 0.42-0.47 vol % 0.41

HEMATOLOGY REPORT
Date: Dec. 03 2015, AM
Examination Desired: Plt, Hct

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS

Thrombocytes 150-400 x 103/mL 168
Fraction 0.42-0.47 vol % 0.44

22
 URINALYSIS REPORT
Date: Nov. 30 2015 AM

NORMAL
PARAMETER RESULTS REMARKS
FINDINGS
COLOR yellow yellow Normal
TRANSPARENCY Clear Clear or cloudy Normal
REACTION 6.5 4.5-8 Normal
SPECIFIC 1.020 1.005-1.030 Normal
GRAVITY
SUGAR negative negative Normal
RBC 1-2/HPF ≤2/hpf Normal
WBC 5-13/HPF ≤2-5/hpf Due to the presence of infection
EPITHELIAL absent absent Normal
CELLS

FECALYSIS REPORT
Date: Dec.01 2015 AM

NORMAL
PARAMETER RESULTS REMARKS
FINDINGS
COLOR brown yellow Normal
CONSISTENCY formed Semi-formed Normal
Findings: No ova and parasite seen

23
 Chapter VIII
Nursing Theory

“Environmental Theory”
By: Florence Nightingale

The environmental theory by Florence Nightingale defined Nursing as “the act of

utilizing the environment of the patient to assist him in his recovery.” It involves the nurse’s
initiative to configure environmental settings appropriate for the gradual restoration of the
patient’s health, and that external factors associated with the patient’s surroundings affect life or
biologic and physiologic processes, and his development.

This particularly correlates with the patient’s case since one of the most important factors
that aids not only in the healing process but also the preventive aspect is the environment. By
manipulating the environment of the patient such as ventilation, light and warmth, the body can
repair itself quickly compared to a poor environment. Also, the environment also contributes a
large part in preventing future cases of dengue. By maintaining a clean environment, it eradicates
possible breeding grounds of mosquitoes that are carriers of the dengue virus.

“Self-care Deficit Theory”

By: Dorothea Orem

Orem’s theory defined nursing as “The act of assisting others in the provision and
management of self-care to maintain or improve human functioning at home level of
effectiveness.” It focuses on each individual’s ability to perform self-care, defined as “the
practice of activities that individuals initiate and perform on their own behalf in maintaining life,
health, and well-being.” Self-care Deficit delineates when nursing is needed. Nursing is required
when an adult (or in the case of a dependent, the parent or guardian) is incapable of or limited in
the provision of continuous effective self-care.

As in the case of patient R.L., he is unable to take care of himself such as doing his
activities of daily living like taking a bath, urinating and defecating, and even eating due to
fatigue, severe pain and discomfort. Thus comes the role of the nurse to fill in the gap and assist
the patient in doing such activities as much as possible.

24
 “Nursing Need Theory”
By: Virginia Henderson

The Nursing Need Theory was developed by Virginia A. Henderson to define the unique focus of
nursing practice. The theory focuses on the importance of increasing the patient’s independence
to hasten their progress in the hospital. Henderson’s theory emphasizes on the basic human needs
and how nurses can assist in meeting those needs.

The nurse’s task in every patient is to assist them in achieving their optimal health. However,
nurses are not always beside their patients and they can’t assist or help them all the time round
the clock. Thus, it is one of the nurse’s responsibilities for the patient to not only achieve optimal
health but also in gradually attaining independence during the healing process. With R.L.’s case,
the nurse slowly allows him to do minor tasks such as eating and going to the bathroom by
himself as long as he can tolerate or do so. The nurse also gave instructions to the patient and his
parents on what must be done after they are discharged from the hospital. This allows the
continuation of care through independence attained by the patient and his significant others.

25
 Chapter IX
Nursing Assessment

REVIEW OF SYSTEMS:

NEUROLOGICAL
Patient appears conscious and responsive. He is oriented to time, place and person. He
also doesn’t appear to have any mental disabilities and is generally mentally well.

EYE/VISION
The patient’s eyes can see clearly and has no problems in distinguishing far objects. The
peripheral conjunctiva appears pinkish and both eyes do not appear red and dry. Eyes and
eyebrows are parallel to each other and symmetrical. Pupils equally round and react to light and
accommodation.

EARS/HEARING
Both ears appear normal without the presence of discharges, impacted cerumen and
foreign objects upon thorough inspection using a pen light. The patient can hear normally
without any difficulty.

NOSE
Nose is patent and appears normal. Nasal mucosa is pink, moist and intact. Nostrils are
patent with no signs of nasal flaring. No discharges and foreign objects observed.

MOUTH/TONGUE/TEETH/SPEECH
The buccal mucosa is pink and has no evident signs of infection. No lesions present on
lips, gums and tongue. However, lips appear slightly dry due to lack of fluid intake. Teeth are
complete with no dentition although there are small signs of tooth decay. The patient has also no
difficulty in speaking and pronounces words correctly.

THROAT/NECK
The throat is pink with normal tonsils and adenoids. Patient can swallow without any
problems and has no signs of infection. The neck appears normal and has no enlarged lymph
nodes upon palpation.

RESPIRATORY SYSTEM

26
 The patient breathes at ease with no signs of respiratory distress. There were also no
adventitious breath sounds upon auscultation. The patient’s respiratory rate is also within normal
range with a rate of 22 cycles per minute.

MUSCULOSKELETAL SYSTEM
The extremities have decreased normal range of motion due to body weakness. The
patient still needs some assistance in doing activities of daily living such as taking a bath. No
tremors or spasms observed on the muscles.

INTEGUMENTARY SYSTEM
The patient’s skin is patent with good turgor which indicates that the patient is hydrated.
No lesions or rashes were noted on the skin although it appeared to be a bit oily and dirty.
Dandruff was noted on the scalp and the patient’s hair is unkempt.

CIRCULATORY SYSTEM
The patient has no signs of cyanosis as evidenced by pinkish conjunctiva and mucosa.
Upon pressing the nails, redness goes back within 3 seconds which indicates that capillary refill
is good. The patient has also no signs of cardiovascular diseases with a pulse rate within normal
range of 87 beats per minute.

GASTROINTESTINAL
Bowel sounds were heard indicative of normal peristalsis. The patient has not
experienced any loose bowel movement and has no signs of indigestion. Upon palpation, no pain
was noted. Percussion of the abdomen yielded a resonant sound.

GENITOURINARY
The patient has a normal urinary frequency of about 3 every 8 hours. He also has no
difficulty in urinating. No pain was noted and has no signs of infection.

PRESENT BEHAVIOR
The patient is very responsive and is in a good mood. He answers the group’s questions
immediately and appropriately. He is also cooperative and open minded to several nursing
interventions that the group administered.

SOCIO-ECONOMIC STATUS
The patient is still a freshman high school student and relies financially to his parents. His
father earns about Php 190 per day.
27
FAMILY CONCERN
The patient is confident that his family can properly take care of himself along with his
siblings. Although he is a bit worried in skipping school due to his illness.

LATEST VITAL SIGNS:

BP-90/60
PR-87 bpm
RR-22 bpm
Temp-36.8oC

28
 Goals
Date/Tim Cues Needs Nursing Scientific Objectives Nursing Rationale Evaluation
e Diagnosis Basis Criteria Interventions

Nov. 30, Sub. N Hyperthermia Pyrogens cause a Within 4 hours of -Establish rapport -Promotes cooperation in the nursing Within 4 hours of
2015 U related to rise in body nursing with the client and care. nursing
“init kayo T inflammatory temperature, it interventions, parents. interventions,
@ akong anak R process also acts as client will be able -Helps to identify the development of client was able to
nurse.” As I antigen triggering to report and show -Monitor vital signs the client’s VS report and show
6 pm verbalized by T immune system manifestations that manifestations that
the mother. I responses. The fever is relieved as -To reduce body temperature through fever was relieved
O hypothalamus evidenced by: the process of conduction as evidenced by:
Obj. N reacts to raise the -Provide TSB
Temp: 39.1°c A set point and the Verbalization of -Water regulates body temp. Verbalization of
RR:32 cpm L body respond by feeling well the client:
PR: 127 bpm - producing heat. “dili na init akong
-pallor M VS within normal -Encourage to -To promote relaxation pamati ate nurse.”
-flushed skin E Fundamentals of range increase OFI
-dry mucous T Nursing -To replenish fluid losses during VS of:
membranes A -Harry & Perry Absence of -Promote bed rest shivering chills Temp= 36.7°c
-muscle B muscular RR= 25 cpm
rigidity; chills O rigidity/chills -Maintain IVF as -To treat underlying causes PR= 92
-malaise L indicated by
I Absence of physician Absence of
C flushing muscular
-Administer rigidity/chills
P medications as order -To know the fluid balance of the
A by physician such as body. Normal
T paracetamol or any complexion of skin
T antipyretic drugs
E
R -Monitor I & O
N

29
 Date/ Goals
Time Cues Needs Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Basis Criteria Interventions
Sub.”sakit P Acute pain Unrelieved After 8 hours of >Instruct client to >unrelieved pain can After 8hours of
ang akong E related to acute pain nursing report may create other problems nursing intervention
12/03/15 join og R tissue injury leads to intervention, improvement in such as anger, anxiety, was the patient able to
@ abdomen”a C secondary to debilitation, the patient will pain experience. immobility,respiratory experience gradual
9:30am s E surgical diminished be able to >Encourage problems and delay relief of pain.
verbalized P intervention. quality of life, experience verbalization of inhealing.
by patient. T and gradual relief feelings about the >only the client can
U depression. pain. pain. judge the level and
Obj. A >Encourage and distress of pain;pain
- L assist client to do management should be
Depression deep breathing a team approach that
-anxiety C exercise. includes the client.
O >deep breathing for
G relaxation is easy to
N learn and contrioutes to
I pai relief and reduction
T by reducing muscle
I tension and anxiety.
V
E

P
A
T
E
R
N

30
 Goals
Date/Tim Cues Needs Nursing Scientific Objectives Nursing Rationale Evaluation
e Diagnosis Basis Criteria Interventions
A
12/03/1 Subj: C Fatigue the level of After/within -established -easily communication “Partially goal met”
5 T Related scientific 8hrs span of rappor to the to client.
“Kapoya I to body evidence care client able client -a plan balance period
presented to develop good -assist the of activity and rest can After/within 8hrs
@ n ko V weaknes
by clinical
usahay I s progress such patient to help patient desired span of care able to
trials of
11:48a maglihok T adaptogens
as: develop a activity develop the:
m gusto Y in fatigue, schedule for -client ability to
lang - and to -absent of daily activity participate in his role to -Absent general body
nako E provide a general body and rest. perform responsibility weakness
mag X rationale at weakness -assess the -to identify client -absent of sense o
higda” as E the -report patient ability to appropriate coping energy
verbalize R molecular improved sense performed behaviors. - OFI
d by C level for of energy. activities of -to maintain the energy
client. I verified -performed daily level in our body.
effects. (Adls) living(adls)
S
Strong -increased OFI -promotes sense
Obj: E scientific -encourage the of control and
evidence is
-lack of P mother to eat improves self
available for
energy A Rhodiola
nutritious food. esteem.
-lethargic T rosea SHR-5 -teach client
-general T extract, strategies for
body E which energy
weaknes R improved conservation
s N attention,
- pale cognitive
function and
skin
mental
noted performance
-drowsy in fatigue

31
- and in
chronic
fatigue
syndrome.

32
 Chapter XI

DRUG STUDY

DATE/T BRAN ACTION INDICATI ROUTE/D DRUG ADVERSE PRECAUTI NURSING

IME D ON OSAGE/ INTERACTI EFFECT ON RESPONSIBILITES
ORDER NAME TIME ON CONTRA-
ED INTERVA INDICATIO
L NS
9/30/15 Ceftin, Second- Pharyngitis, Orally, 1 tab Drug-drug. CV: Hypersensitivit  Lab tests: Perform culture and
5:30 am Zinnat generationc tonsillitis,inf 250 mg tid Aminoglycoside phlebitis, y to sensitivity tests and renal
ephalospori ections of for 3 days s: Produces thrombophle cephalosporin function studies before and
n that the urinary synergistic bitis and penicillin periodically during drug
Onset: therapy.
inhibits andlower activity against
unknown  Absorption of cefuroxime is
cell-wall respiratory some organisms; GI:
enhanced by food
synthesis, tracts, increases risk of pseudomemb
Peak: 15-60  Tablets can be crushed if
promotingo andskin and nephrotoxicity. ranous patient can’t swallow tablets
min
smotic skin- Monitor patient colitis,  Tell patient to take the drug as
Generic
instability; structureinfe Duration: closely. nausea, prescribed even if he is already
Name
usually ctions Diuretics: anorexia, feeling better
unknown
Cefurox bactericidal caused Increases risk of vomiting,  Instruct patient to notify
. byStreptoco adverse effects. diarrhea. prescriber about rash or
ime
evidence of superinfection.
axetil ccus Monitor patient
Hematologic  Tell patient to notify prescriber
pneumoniae closely. about loose stools or diarrhea.

33
 and S. Half Life Probenecid: : transient
pyogenes,H Competitively neutropenia,
aemophillus 1-2 hours inhibits renal eosinophilia,
influenzae,S tubular secretion hemolytic
taphylococc of anemia,
us cephalosporins, thrombocyto
aureus,Esch resulting in penia,
erichia coli higher, decreased
prolonged serum hemoglobin
levels of these and
drugs. hematocrit.
Sometimes used
for this effect. Skin:
Drug-food. Any maculopapul
food: Increases ar and
absorption. erythematous
Advise patient rash,
to take drug urticaria,
with food. pain,
induration,
sterile
abscesses,
temperature
CLASSI Absorption Excretion elevation,
FICATI tissue
ON Well Renal, sloughingat
absorbed unchanged injection site.
Anti- after oral or
infectiv subcutaneous Other:
e administratio hypersensitiv
n ity reactions
(serum
sickness,
anaphylaxis).

34
 DATE/ BRAND ACTION INDICATION ROUTE/D DRUG ADVERSE PRECAUTI NURSING
TIME NAME OSAGE/ INTERACTI EFFECT ON RESPONSIBILITES
ORDERED TIME CONTRA-
ON
INTERVA INDICATIO
L NS
11/30/15 Biogesic, Unknown Mild pain Orally, Barbiturates, CV: Hypersensitiv  Use liquid form for
5:30 am Tempra, . Thought or fever 500mg carbamazepin hemolytic ity drugs snf children with difficulty in
Tylenol to every 4 e, rifampin, anemia, acute swallowing.
produce hours PRN sulfinpyrazon leukopenia, intoxication  Don’t exceed 5 doses in 24
hours
analgesia e: high doses neutropenia, with alcohol
Onset:  Tell patient that drug is
by or long term pancytopenia
Unknown only for short term use
blocking use of these ,  Tell patient to not use for
Peak: ½ -
pain drugs may thrombocyto fever exceeding 39.5oC or
Generic 2 hours
impulses, reduce penia those exceeding 3 days
Name unless prescribed
probably Duration: therapeutic
by effects and Hepatic:  Warn patient that long term
Paraceta 3-4 hours Liver
inhibiting ehance use can cause liver damage
mol Half life damage,
synthesis 1-4 hours heptotoxic
jaundice
of effects of
prostagla paracetamol Metabolic:
ndin in hypoglycemi
the CNS Drug-food:
a
Caffeine: May
enhance Skin: rash,
analgesic
35
 effects of urticaria
paracetamol

CLASSI Absorption Excretion:

FICATIO : Urine 85%
N Readily -90%
absorbed
Analgesi from the
c, gastrointest
antipyreti inal tract
c

36
 Chapter XII
Health Teachings

Medication

• Intake of Vitamin B-complex supplement to increase protection mechanism of the

immune system.

• Take medications on time and the right dosage to achieve the maximum therapeutic
effects of drugs.

Lifestyle

• Enough sleep and rest periods to conserve energy.

• Increase oral fluid intake for hydration.

• Maintain proper hygiene such as taking a bath everyday.

• Eat more nutritious foods such as green leafy vegetables and fruits.

Management

• Use personal protection such as full-covering clothing, netting, and using mosquito
repellent.

37
 Chapter XIII
Discharge Plan

Medications:

 Remind to take the prescribed medicine, having a written reminder of the correct
medication, time to take, and the right frequency of the medicine on the way home to
establish assurance of medication compliance.
 Give acetaminophen in case the temperature increases.
 Give oresol to replace fluid in the body
 Don’t give NSAID’s, they increase the risk of bleeding. Any medicines that decrease
platelet count should be avoided.

Exercise:

 Instruct to avoid excessive activities that may result to stress.

 Advised to perform range of motions and repetitive body movements for promotion
of optimum

Treatment:

 Currently, no medications are available to treat dengue hemorrhagic fever.

 Instruct the client to increase the oral fluid intake.
 Instruct the client to have complete bed rest

Hygiene:

 Teach client as well as the parents the preventive measures such as proper way of hand
washing, taking a bath everyday and wear long-sleeved clothes and long trousers when
outdoors, especially in areas close to bushes, ponds, and wetlands.

Outpatient Orders:

 Instruct the family members to have a check-up or to consult physician once a while to
monitor patient’s condition and for detection of recurrences and other complications that
may arise on to it.

38
Diet:

 Encourage nutritious foods like vegetables, meat and fruits.

 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, vitamin C rich foods such
as guava and tomatoes and other citrus fruits, and carbohydrates rich food such as breads
and rice
 Instruct to drink a lot of water, at least 8-10 glasses of water a day.

Significant Others:

 Encouraged significant others to maintain clean and safe environment at all times by
disposing household garbage everyday into the refuse bins, covering all containers that
hold water and to clear the water accumulated on tray beneath refrigerator at least once
every week to prevent mosquito from accessing the water, and to use insecticides in the
house once in a month.

39
 Chapter XIV
Prognosis

Good Fair Poor Justification

Duration √ Patient is infected with

dengue virus for about
10 days in which the
normal incubation
period is 10-14 days
Onset of illness √ Patient diagnose with
high fever 39.1oC
temperature and
vomiting

Complication of √ Patient already

medication understand the
importance of
medication and
compliance
Family support √ The Patient parent
strongly support their
son on the development
of his status

Environment √ The ambiance of the

room is poor
ventilation also hygiene
and waste segregation

Age √ Dengue affects in all

Precipitating factor
ages. However,
children and teenagers
are mostly affected due
to increase outdoor
activity
√ Patient diagnose
dengue with fever
decrease platelet level

40
Summary:
Good: 3/7 x 100 = 42.85%
Fair: 4/7 x 100 = 57.14%
In general, the patient is in fair prognosis which is at 57%

Chapter XV
Evaluation

41
 Awareness is the first step in prevention dengue fever. People should make sure they are
aware of whether there is a risk of dengue infection and be ready to protect themselves if they are
traveling to a region where infection is common. The multiplication of the mosquito that carries
the dengue virus can be prevented by ensuring all areas are clear of potential breeding sites. The
role of nursing care is to disseminate appropriate information on protection and prevention by
following necessary precautions to help reduce risk of catching dengue fever.

42
 Chapter XVI
Implication of the Study

43
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