OBJECTIVES

General

This case presentation aims to identify and determine the general heath problems and needs of the patient with an admitting
diagnosis of Dengue Hemorrhagic Fever, Type 1. This presentation also intends to help patient promote health and medical
understanding of such condition through the application of the nursing skills.

Specific

 To raise the level of awareness of patient on health problems that she may encounter.
 To facilitate patient in taking necessary actions to solve and prevent the identified problems on her own.
 To help patient in motivating her to continue the health care provided by the health workers.
 To render nursing care and information to patient through the application of the nursing skills

INTRODUCTION

Dengue fever is found mostly during and shortly after the rainy season in tropical and subtropical areas of

■Africa■Southeast Asia and China■India■Middle East■Caribbean and Central and South America■Australia and the South and
Central Pacific

You can get dengue virus infections from the bite of an infected Aedes mosquito. Mosquitoes become infected when they bite
infected humans, and later transmit infection to other people they bite. Two main species of mosquito, Aedes aegypti and Aedes
albopictus, have been responsible for all cases of dengue transmitted in this country. Dengue is not contagious from person to
person

Symptoms of typical uncomplicated (classic) dengue usually start with fever within 5 to 6 days after you have been bitten by an
infected mosquito and include:

 High fever, up to 105 degrees Fahrenheit

 Severe headache
 Retro-orbital (behind the eye) pain
 Severe joint and muscle pain
 Nausea and vomiting
 Rash

The rash may appear over most of your body 3 to 4 days after the fever begins. You may get a second rash later in the disease.
Symptoms of dengue hemorrhagic fever include all of the symptoms of classic dengue plus

 Marked damage to blood and lymph vessels

 Bleeding from the nose, gums, or under the skin, causing purplish bruises

This form of dengue disease can cause death.

Symptoms of dengue shock syndrome-the most severe form of dengue disease-include all of the symptoms of classic dengue and
dengue hemorrhagic fever, plus

 Fluids leaking outside of blood vessels

 Massive bleeding
 Shock (very low blood pressure)

XI. PATHOPHYSIOLOGY Medical Diagnosis T/C Dengue Hemorrhagic Fever/ Pleural Effusion, T/C Liver Pathology
Definition Dengue Hemorrhagic Fever - is a severe, potentially deadly infection spread by certain species of mosquitoes (Aedes
aegypti). Pleural Effusion - is excess fluid that accumulates in the pleural cavity, the fluid-filled space that surrounds the lungs.
Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during inhalation. Liver Pathology –
a condition characterized by any liver diseases or condition

Schematic Diagram
#Predisposing
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 aegypti (dengue virus carrier): 8-12 days of viral replication on mosquitos’salivary g lands

#Bite from mosquito (Portal of Entry in

the Skin)
#Allowing dengue virus to be inoculated,towards the circulation/blood (Incubation period 3-14 days)

#Virus disseminated rapidly into the bloodand stimulates WBCs including Blymphocytes that produces and
secretesimmunoglobulins (antibodies), andmonoc
y tes/macro p h g es, neutrop hils

#Diagnostic:..Hematology :Increased WBC:12,900/cumm(5,000- 10,000/cumm)IncreasedLymphocytes: 49% (20-40%)

#Diagnostic:Hematology :DecreasedMonocytes:4%(8-14%) DecreasedNeutrophils:49%(50-70%)

#Antibodies attach to the viralantigens, and thenmonocytes/macrophages will perform phagocytosis through Fcreceptor (FcR)
within the cells andengue virus replicates in the cells
Grade I - thrombocytopenia + hemoconcentration. Absence of spontaneous bleeding.
Grade II - thrombocytopenia + hemoconcentration. Presence of spontaneous bleeding.
Grade III - thrombocytopenia + hemoconcentration. Hemodynamic instability: filiform pulse, narrowing of the pulse pressure (<
20 mmHg), cold extremities, mental conffusion.
Grade IV - thrombocytopenia + hemoconcentration. Declared shock, patient pulseless and with arterial blood pressure = 0
mmHg (dengue shock syndrome - DSS).

 pathophysiological changes occur in DHF/DSS:

 Increased vascular permeability

 haemoconcentration(Hct>20%)

 low pulse pressure

 other signs of shock.

 Disorder in haemostaisis :

 vascular changes

 thrombocytopenia
  coagulopathy.

 restlessness;

GRADING THE SEVERITY OF DENGUE FEVER:

Grade 1:>fever>non-specific constitutional symptoms such as anorexia, vomiting and abdominalpain

>absence of spontaneous bleeding

>positive tourniquet test

Grade 2:>signs and symptoms of Grade 1: plus

>presence of spontaneous bleeding: mucocutaneous, gastrointestinal

Grade 3:>signs and symptoms of Grade 2 with more severe bleeding: plus

>evidence of circulatory failure: cold, clammy skin, irritability, weak to

compressible pulses, narrowing of pulse pressure to 20 mmhg or less, cold

extremities, mental confusion

Grade 4:>signs and symptoms of Grade 3, declared shock, massive bleeding, pulse less

and arterial blood Pressure = 1 mmhg (Dengue Syndrome/DS)

DIAGNOSTIC TEST:Tourniquet test

>Inflate the blood pressure cuff on the upper arm to a point midway between the

systolic and diastolic pressure for 5 minutes.

>Release cuff and make an imaginary 2.5 cm square or 1 inch square just below

the cuff, at the antecubital fossa.

>Count the number of petechiae inside the box. A test is positive when 20 or more

petechiae per suare are observed.

introduction

Dengue haemorrhagic fever (DHF), a potentially lethal complication, was first recognized in the 1950s during the dengue
epidemics in the Philippines and Thailand, but today DHF affects most Asian countries and has become a leading cause of
hospitalization and death among children in several of them.

Last June 16, 2008, I encountered a patient with such kind of infection. This patient has caught my attention and has given the
opportunity to study his case. The objective of this study is to help me understand the disease process of Dengue Fever and to
orient myself for appropriate nursing interventions that I could offer to the patient. This approach enables me to exercise my
duties as student nurse which is to render care. I was given the chance to improve the quality of care I can offer and to pursue my
chosen profession as future nurse.

I humble myself to present my studied case and submit myself for further corrections to
widen the scope of my knowledge and understanding.

DENGUE PREVENTION:

There is no vaccine to prevent dengue. Prevention centers on avoiding mosquito bites

when traveling to areas where dengue occurs and when in U.S. areas, especially along the Texas-
Mexico border, where dengue might occur. Eliminating mosquito breeding sites in these areas is
another key prevention measure.

Avoid mosquito bites when traveling in tropical areas:

 Use mosquito repellents on skin and clothing.
 When outdoors during times that mosquitoes are biting, wear long-sleeved shirts and
long pants tucked into socks.
 Avoid heavily populated residential areas.
 When indoors, stay in air-conditioned or screened areas. Use bednets if sleeping areas
are not screened or air-conditioned.
 If you have symptoms of dengue, report your travel history to your doctor.
Eliminate mosquito breeding sites in areas where dengue might occur:
 Eliminate mosquito breeding sites around homes. Discard items that can collect rain
or run-off water, especially old tires.
 Regularly change the water in outdoor bird baths and pet and animal water containers

NURSING HISTORY
Present Health History:

Three days prior to admission the patient has fever and loss his appetite. According to the SO of the
patient, they went to consult a physician during the first day of his fever. The physician prescribed Paracetamol for
the patient. On the third day, the patient still had the said symptoms. He went back for a check-up. He had CBC and
was determined that he has dengue. The patient then was admitted immediately to Saint Paul Hospital on June 14,
2008.

Past Health History:

According to the SO of the patient the patient did not yet experienced having serious
health problems other than fever, colds and cough. He had no previous hospitalization.
Family Health History:
According to the SO of the patient, their family has the history of Hypertensio
HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

Before hospitalization: The patient perceived his health in the state of good condition. He perceives
health as wealth and he values his health a lot. He manages his health by practicing proper hygiene and
eating nutritious food.

During hospitalization: He sees himself as a total ill person because he cannot do anymore the things he
usually does like playing with his siblings. He rely his present condition with the help of the therapeutic
personnel and by following the prescribed medications. The patient perceived that he is not healthy
because of his condition.
NUTRITIONAL-METABOLIC PATTERN

Before hospitalization: The patient eats 3 times a day and with afternoon snacks after coming from
school. According to the SO of the patient, he eats meat, fish and also vegetables. He doesn’t have any
allergies on foods and drugs. His appetite is moderate and usually depends on the food being served. He
didn’t complain any difficulty in swallowing.

During hospitalization: The patient has loss his appetite and hasn’t eaten a lot. He is on a DAT (Diet as

Tolerated) EDCF (Except Dark Colored Foods).

ELIMINATION PATTERN

Before hospitalization: the patient does not have any problem on his elimination pattern. He usually
urinates 4-5 times a day without any difficulty. He added that the color of his urine is light yellow. He
didn’t feel any pain in urination. The patient defecates once a day usually early in the morning before
going to school with yellow to brown color. He verbalized that sometimes however, it is hard in
consistency with dark color, which generally depends on what he eats.

During hospitalization: The patient urinates 2-3 times a day. The color of her urine is yellow. The patient
defecates once every two days.

SLEEP-REST PATTERN

Before hospitalization: He has the normal 6-8 hours sleep. He also has his nap time for 1-2 hours a
day.Sleeping and watching the television are his form of rest.

During hospitalization:He doesn’t have the adequate time of sleep since he is disturbed with the nurses
that enter the room every now and then, and because of the environmental changes of his
surroundings. He also has inadequate time to rest since he doesn’t have enough time to sleep.

REVIEW OF ANATOMY AND PHYSIOLOGY

BLOODBlood is considered the essence of life because the uncontrolled loss of it can result to

death. Blood is a type of connective tissue, consisting of cells and cell fragments surrounded by a
liquid matrix which circulates through the heart and blood vessels. The cells and cell fragments
are formed elements and the liquid is plasma. Blood makes about 8% of total weight of the body.

Functions of Blood:
>transports gases, nutrients, waste products, and hormones
>involve in regulation of homeostasis and the maintenance of PH, body temperature, fluid
balance, and electrolyte levels
>protects against diseases and blood loss
PLASMA

Plasma is a pale yellow fluid that accounts for over half of the total blood volume. It
consists of 92% water and 8% suspended or dissolved substances such as proteins, ions,
nutrients, gases, waste products, and regulatory substances.

Plasma volume remains relatively constant. Normally, water intake through the GIT
closely matches water loss through the kidneys, lungs, GIT and skin. The suspended and
dissolved substances come from the liver, kidneys, intestines, endocrine glands, and immune
tissues as spleen.

PREVENTING BLOOD LOSS

When a blood vessel is damaged, blood can leak into other tissues and interfere with the normal tissue function or blood
can be lost from the body. Small amounts of blood from the body can be tolerated but new blood must be produced to
replace the loss blood. If large amounts of blood are lost, death can occur.

BLOOD CLOTTING

Platelet plugs alone are not sufficient to close large tears or cults 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, which traps blood cells, platelets and fluids.

The formation of a blood clot depends on a number of proteins found within 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 chemical reactions, but it can be summarized in 3 main stages; the
chemical reactions can be stated in two ways: just as with platelets, the contact of inactive clotting factors with exposed
connective tissue can result in their activation. Chemicals released from injured tissues can also 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 clotting factor in the series until the clotting factor
prothrombin activator is formed. Prothrombin activator acts on an inactive clotting factor called prothrombin.
Prothrombin is converted to its active form called thrombin. Thrombin converts the inactive clotting factor fibrinogen
into its active form, fibrin. The fibrin threads form a network which traps blood cells and platelets and forms the clots.

CONTROL OF CLOT FORMATION

Without control, clotting would spread from the point of its initiation throughout the entire circulatory system. To
prevent unwanted clotting, the blood contains several anticoagulants which prevent clotting factors from forming clots.
Normally there are enough anticoagulants in the blood to prevent clot formation. At the injury site, however, the
stimulation for activating clotting factors is very strong. So many clotting factors are activated that the anticoagulants no
longer can prevent a clot from forming. area and the formation of the new connective tissue. In addition, epithelial cells
around the

wound divide and fill in the torn area.

The clot is dissolved by a process called fibrinolysis. An inactive plasma protein called plasminogen is converted to its
active form, which is called plasmin. Thrombin and other clotting factors activated during clot formation, or tissue
plasminogen activator released from surrounding tissues, stimulate the conversion of plasminogen to plasmin. Over a
period of a few days the plasmin slowly breaks down the fibrin.

CLOT RETRACTION AND DISSOLUTION

After a clot has formed, it begins to condense into a denser compact structure by a process known as clot retraction.
Serum, which is plasma without its clotting factors, is squeezed out of the clot during clot retraction. Consolidation of the
clot pulls the edges of the damaged vessels together, helping the stop of the flow of blood, reducing the probability of
infection and enhancing healing. The damaged vessel is repaired by the movement of fibroblasts into damaged

DRUG STUDY

ISOPRINOSINEDosage: 2 tsp TID 250 mg

Classification: Antivirals

Indication:Rhinovirus; herpes genitalis; measles; encephalitis; influenza; herpes zoster; herpessimplex; type A & B hepatitis;
AIDS related complex; neoplastic diseases; anergy andhypoergy prior to major surgery

Action:>Synthetic antiviral: it stimulates T-lymphocytes; used for HIV and Hepatitis>non-toxic immune system stimulant

Adverse Reactions:>Transient increase in urine and serum uric acid level; very rarely skin rashes; pruritis;GI upset; nausea;
fatigue; malaise

Contraindications:>Hypersensitivity. Patients w/ adnormally low neutrophil counts (< 0.75 x 10x9/L), orabnormally low
haemoglobin levels (< 7.5 g/dL or 4.65 mmol/L)

Nx Considerations:>Monitor increase in serum uric acid level, gout, urolithiasis or renal dysfunction;pregnancy and
lactation>Monitor hematological parameters

Patient Teaching:>Inform patient that the drug must be taiken 1 hour apart on an empty Stomach>Instruct the patient to notify
prescriber if unusual effects occurs

AMOXICILLIN

Dosage: 375 mg TID

Classification : Antibiotic

Indication: Infections due to susceptible strains; helicobacter pylori infections in combination

with other agents; post-exposure prophylaxis against bacillus anthracis;Chlamydia

trachomatis in pregnancy

Action: Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death

Adverse Reactions:>CNS – lethargy, hallucinations, seizures>GI – glossitis, stomatitis, gastritis, sore mouth, furry tongue
(black hairy), nausea,vomiting, diarrhea (bloody), enterocolitis,pseudomembranous colitis, nonspecifichepatitis>GU –
nephritis>Hematologic – anemia, thrombocytopenia, leucopenia, neutropenia, prolonged bleedingtime>Hypersensitivity – rash,
fever, wheezing, anaphylaxis>Others – superinfections: oral and rectal moniliasis, vaginitis

Contraindications:>Contraindicated with allergy to cephalosporins or penicillins, or other allergens>Use cautiously with renal
disorders and lactation

Nx Considerations:>Culture infected area prior to treatment; reculture area if response is not expected>Give in oral preparations
only; amoxicillin is not affected by food>Continue therapy for at least 2 days after signs of infection have
disappeared;continuation for 10 full days is recommended>Use corticosteroids or antihistamines for skin reactions

Patient Teaching:>Take this drug around-the-clock>Take the full course of therapy; do not stop because you feel better>This
antibiotic is specific for this problem and should not be used to self-treat otherinfections>Eat frequent small meals to avoid GI
effects; frequent mouth care may prevent sore
mouth>Report unusual bleeding or bruising, sore throat, fever, rash, hives, severe diarrhea,
difficulty of breathing

PARACETAMOL

Dosage: 250 mg/5ml q 4° RTC

Classification: Nonopioid Analgesics & Antipyretics

Indication: Mild pain or fever

Action: Produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances
that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulating
center.

Adverse Reactions:
Hematologic: Hemolytic Anemia, Neutropenia, Leukopenia, Pancytopenia
Hepatic: Jaundice
Metabolic: Hypoglycemia
Skin: Rash, Urticaria

Contraindications: Contraindicated in patients hypersensitive to drug. Use cautiously in patients with long-term alcohol
use because therapeutics doses cause hepatotoxicity in these patients. Nx Considerations: ALERT: Many OTC and
prescription products contain acetaminophen; be aware of this when calculating total daily dose. Use liquid form for children
and patients who have difficulty in swallowing. In children, don’t exceed five doses in 24 hours.

Patient Teaching: Tell parents to consult prescriber before giving drug to children younger than age 2. Advise patient or
parents that drug is only for short-term use; urge them to consult prescriber if giving to children for longer than 5 days or adults
for longer than 10 days. ALERT: Advise patient or caregiver that many OTC products contain acetaminophen, which should
be counted when calculating total daily dose. Tell patient not to use for marked fever (temperature higher than 103.1°F
[39.5°C]), fever persisting longer than 3 days, or recurrent fever unless directed by prescriber. ALERT: Warn patient that high
doses or unsupervised long-term use can cause liver damage. Excessive alcohol use may increase the risk of liver damage.
Caution long- term alcoholics to limit acetaminophen intake to 2g/day or less. Tell breast-feeding woman that acetaminophen
appears in breast milk in low levels (less than 1% of dose). Drug may be used safely if therapy is short-term and doesn’t exceed
recommended doses.

FORMED ELEMENTS

OBJECTIVES: At the end of the rotation, I will be able to:

To upgrade my knowledge on clinical setting

To familiarize myself with the hospital setting
To deliver health care services.
To build rapport with the patients, SOs, staff nurses, clinical instructor and student nurses.
To enhance my skill on therapeutic communication

The first rotation of my duty was in St. Paul Hospital and unexpectedly my schedule is night shift. I’m nervous at the first night
of duty because I still don’t know what to expect in a hospital setting. The first night was like an orientation for us. We were only
tasked to do the vital signs taking and plotting. We weren’t allowed yet to do the charting and giving of medications.

The patients given to us were in the Holy Family Ward. My first patient was a three year old boy whose chief complaint was
contusion hematoma. It was good that I was paired with a Chinese student because I have someone to help me in taking the vital
signs. The only disadvantage of having paired with her is that it is difficult to explain everything to her because language
difference.
Having a night duty has positive and negative factors. The positive or advantage of night duty is that you are not toxic with many
things to do. At night shift, you also have the time to browse the chart of the patient. The negative or disadvantage part is that you
have to make yourself awake for about eight hours. Another disadvantage is that it is difficult to interview and assess the patient
because it is his/her time to sleep and rest. Interaction among the group is really needed to keep all of us awake.

In next nights of our duty, we had our patients staying in Sto. Niño Ward. We were already tasked to do charting. Doing the
charting every night enhances my skill and ability in doing it. Interviewing the SOs of the patient assigned to me was not difficult
because they were so cooperative and kind. I was lucky to have patients that don’t have lot of tantrums even if they are still kids.

Experiencing the clinical or hospital setting makes me feel excited of my future job. I believe that I must do everything correctly
for the benefit of my patients. It is a good and relieving feeling that the patient you handle will be discharged immediately.

The most unforgettable experience of my first rotation of duty was that someone died. My heart that time was like stubbed with a
knife that I can’t breathe. Through this case, I instilled in my mind that I must be relax and do the things necessary to revive a
life. Panicking during such case will not do anything good. The first rotation of duty had left me with so many experiences that
taught me a lot of things to remember.

FORMED ELEMENTS:CELLS TYPE

Erythrocytes (RBC-discription.. Biconcave disk, no nucleus, 7-8 micrometers in diameter.Fucntion-

Transport oxygen and carbon dioxide

Leukocytes (WBC):Neutrophil-Spherical cell, nucleus withtwo or more lobes connectedby thin

filaments, cytoplasmicgranules stain a light pink orreddish purple, 12-15micrometers in diameter-
Phagocytizes microorganism

Basophil- Spherical cell, nucleus, withtwo indistinct lobes,cytoplasmic granules stainblue-purple, 10-
12micrometers in diameter- Releases histamine, whichpromotes inflammation, and heparin
whichprevents clotformation

Eosinophil- Spherical cell, nucleus often bilobed, cytoplasmic granulessatin orange-red or bright red,
10-12 micrometers in diameter- Releases chemical that reduce inflammation, attacks certain
worm parasites

Lymphocyte- Spherical cell with roundnucleus, cytoplasm forms athin ring around the nucleus,
6-8 micrometers in diamete- Produces antibodies and otherchemicals responsible fordestroying
microorganisms,responsible for allergicreactions, graft rejection,tumor control, and regulation