I.

Introduction

Dengue Fever is an acute febrile disease cause by infection with one of the
serotypes of dengue virus which is transmitted by mosquito genus Aedes. It refers to a
benign form of disease with systemic symptom, fever, and often rash associated with pain
behind the eyes, the joints, and the bones.

Dengue Hemorrhagic Fever is a severe, sometimes fatal manifestation of dengue

virus characterized by bleeding diathesis and hypovolemic shock. The causative agent of
Dengue is is Flavivirus 1,2,3,4 a family of Togaviridae which are small viruses that
contains a single strand RNA. Another etiologic agent is the Arbovirus group B.

The mode of transmission is via a bite of an infected mosquito, principally the

Aedes Egypti. Aedes Egypti is a day-biting mosquito which attacks two hours after
sunrise and two hours before sunset. This insect breeds in clean stagnant water. It has a
limited flying movement, and has fine white dots at the base of the wings; with white
bands on the legs.

The incubation period is 4-6 days.

The source of infection is either an infected person, where the virus os present in
the blood of patients during the acute phase of the disease and will become a reservoir of
virus, sucked by mosquitoes which may then transmit the disease. The other sourse is via
a standing water, or any stagnant water along the household or premises which are usual
breeding sites of mosquitoes.

The disease may occur at any age, but it is most common among children and
peaks between 4 – 9 years old. Both sexes can be affected. It is more frequent during the
rainy season. Dengue fever is more prevalent in urban communities.

Dengue hemorrhagic fever is classified as Grade I, II, III, and IV. In Grade I,
there is fever with non-specific constitutional symptoms and the only hemorrhagic
manifestation is positive tourniquet test. In Grade II, all signs of Grade I plus spontaneous
bleeding from the nose, gums, GIT are present. Grade III, there ias a presence of
circulatory failure as manifested by weak pulse, narrow pulse pressure, hypertension,
cold clamy skin and restlessness. Grade IV, there is profound shock, undetectable blood
pressure and pulse.

This case study has a diagnosis of Dengue hemorrhagic fever Type II.

Treatment modalities include, analgesic drugs other than aspirin, intravenous

infusion, blod transfusion, oxygen therapy and sedatives. However, there is no effective
anti-viral therapy for dengue fever.

Page | 1
 The diagnostic tests include tourniquet test, platelet count, hematoconcentration,
occult blood and hemoglobin determination.

The WHO says some 2.5 billion people, two fifths of the world's population, are
now at risk from dengue and estimates that there may be 50 million cases of dengue
infection worldwide every year. The disease is now endemic in more than 100 countries.

In the Philippines there are 57,819 reportes cases, on which there are 548 deaths
recorded in the year 2009.(www.who.com)

Last 2008, from January 1 to January 21, the number of people rushed to the San
Lazaro Hospital in Manila for showing early signs of the deadly disease had already shot
past 600. Department of Health (DOH)

REASONS FOR CHOOSING THE CASE

Since that Dengue Hemorrhagic Fever is greatly escalating, the group decided to
choose this case to widen their knowledge and to have the chance to assess a client with
this kind of condition. The nursing students was captivated to know more about the
disease, what caused the disease, how it is treated, and what are the appropriate nursing
interventions for this kind of condition. This case study is carried out to be able to learn
fully the disease process not just from the book but from the patient based as well.

This case study will provide broader comprehension about the condition through
research and actual observation it will serve as a training ground and practice in
developing learned skills in the assessment and management of DHF. Through this case
study, a holistic approach in assessing patient’s health will be delivered, where it can be
immediately attended to and given proper interventions. It serves as a way to familiarize
the students with the different medical approaches toward the ongoing curative phase.
Furthermore, this study may be used as a spring board for a more advanced and in-depth
study that is in accordance to changing and developing society.

Importance of the Case Study

On the part of the group, this case study can be of assistance to all members to
gain empirical information regarding the disease process, its etiology, pathophysiology,
clinical manifestations as well as the standard medical and nursing management

Page | 2
consequently that the group may apply this newly-acquired familiarity, understanding
and comprehension to their client as well as similar situations in the future. The group
was able to attain innovative clinical skills, knowledge, and attitude as well as to sharpen
their contemporary clinical skills essential in the management of the client with Dengue
Hemorrhagic Fever. Through this study, the group members was able to develop a
sagacity of magnanimous love and compassion in rendering nursing care; so that the
group may be able to provide potential clients with a higher height of holistic perception
as well as personage care.

Furthermore, this case study has the potential to provide additional information in
the field of nursing research and networking which are included in the objectives of both
the school and of San Lazaro Hospital.

Objectives (Nurse-Centered)

General Objectives

The foremost focus of this schoolwork is to be able to come up with a

thorough study of Dengue Hemorrhagic Fever and to discover as well as supply an
suitable and precise nursing measure and different errands to deem while taking heed of
the client’s needs.

Specific Objectives

This learning aims to:

1 Assess properly to determine the contributing factors regarding the client’s

disease and identify any present abnormalities

a. Personal Data

b. Family history of health and illness

c. History of past illness

d. History of present illness

e. 13 areas of assessment

2. Gather the needed data that can help to understand how and why the disease occurs

Diagnostic and Laboratory Procedures

f. Anatomy and Physiology

g. Pathophysiology book base and client centered

Page | 3
 2. Develop an individualized plan considering client characteristics or the
situation and setting a specific, measurable, attainable, realistic and
time bounded plan that reflect the onset, date of problem identified

a. Planning (nursing care plan)

3. Provide an appropriate interventions for every problems encountered

and monitor the client’s response to treatment and therapies through
means of physical assessment and communication with the client

a. Medical management

b. Surgical management

c. Nursing management

4. Judge the effectiveness of chosen interventions, nursing care, and the

quality of care provided

a. Client’s daily program in the hospital

5. Describe the general condition of the client upon discharge and know
the take home medications, exercise, treatment for the client, provide
health teachings and inform client for OPD follow-ups

a. Discharge Planning

6. Broaden the knowledge of each member through further research

about the latest news articles and journals regarding to the client
disease

a. Related literature

II. NURSING PROCESS

A. ASSESSMENT

1. Personal Data

a. Demographic Data

Name: Ms. H

Age: 13 years old

Page | 4
 Sex: Female

Chief Complaint: Epistaxis

Blood Type: Type O +

Date of Admission: December 13, 2010

Admitting Diagnosis: Dengue Hemorrhagic Fever II

Final Diagnosis: Dengue Hemorrhagic Fever II

b. Environmental Status

The patient together with her father, mother and three other relatives,
currently reside in Capas Tarlac. They live in a bahay kubo made up of bamboo
and nipa without flooring. The father also noted that there are plenty of breeding
sites for mosquitoes in the vicinity, such as open drainage which expels a foul
odor, stagnant water, tree and flowers, and unkempt surroundings. Due to those
factors, it is but normal for them to see mosquitoes all around the place, and they
stated that each and every one of them has been bitten by the mosquitoes.
According to the father, his daughter was not the first to have dengue in their
neighborhood.

c. Lifestyle

The patient’s daily living activities usually start when she wakes up at 9 in
the morning. She usually spends her leisure time playing with her neighbor and
friends in their backyard. She is fond of eating junkfoods and drinking softdrinks.
She usually consumes pork, junkfoods and at least an 8 oz bottle of softdrinks
daily. She likes eating vegetable, banana and kamote. She defecates every other
day and voids 5 times a day. She usually sleeps at around 9-10pm.

Page | 5
 2. Family history of Health and Illness

Paternal Maternal

HP
N TB

AS
T

Legend:
Living Male TB Tuberculosis

Living Female AST Asthma

Patient HPN Hypertension

Deceased

Page | 6
3. History of Past Illness

The patient’s current hospitalization was her second hospitalization. She

said that when she was three years old, she was rushed to a hospital due to
asthma. She has no memory of other details such as how long was her stay there,
the medications and the treatments she received. After that, whenever she feels
ill and/or hot, her mother will buy her OTC drugs such as Biogesic and Alaxan.
She said that she used to take the medications three times a day until she got
well. Aside from self-medication, they also advocate bed rest and hot foods such
as soup to hasten recovery. She denied practice of herbal medicines,
consumption and application. She said that she didn’t undergo any kind of
operation or any accidents. She stated to have no allergy of all kinds (foods,
dust, etc.). Her father stated that she had completed her immunization.

4. History of Present Illness

The patient had experienced episodes of being bitten by mosquitoes

especially at night, though she stated that mosquitoes were present all the time.
Five days prior to admission, the patient reported that she had an intermittent high
grade fever in the morning accompanied by a 5/10 non-radiating epigastric pain.
Episodes of vomiting which was whitish and small in amount (1/2 cup) from her
previously ingested food. She also stated that she had nausea and anorexia. The
patient consulted a local physician who prescribed three unrecalled medications
for management of fever and epigastric pain.

Two days prior to admission, the patient reported that she had persistent
fever and other symptoms now accompanied by epistaxis of bright red blood from
her left nares amounting to about a cup, which was managed by lying in bed with
head arched back and by putting a cold face towel on her forehead. She told the
group that this temporarily stopped blood from oozing from her nose.

Patient tolerated the symptoms until few hours prior to admission. When
she experienced increased frequency of episodes having epistaxis, fever, rash,

Page | 7
 nausea and vomiting, and anorexia she was then brought to the hospital, hence her
admission.

5. Physical Assessment (IPPA)

Thirteen (13) Areas of Physical Assessment

Date: December 13, 2010

I. Social Status

Pt. X is a 13 year old girl, who lives with her parents and two other
relatives. His father is a construction worker while his mother is a housewife. Pt.
X is an on-going 1st year HighSchool student. They described their family as a
harmonious one, with no apparent serious conflicts among its members. The
patient confidently stated that her family will always be there especially now that
she was sick. She said that it was one of the many things that helped her in the
recovery of her illness.

Norms:

Social status includes family relationships that state the patient’s support
system in time of stress and in time of need. It meets a fundamental human need
for social ties, making life less stressful and social support buffers the negative
effects of stress, thus indicating indirectly contributing to good health outcomes.
(Fundamentals of Nursing, Barbara Kozier; 7th edition).

Imterpretation:

The patient’s social status indicates an effective support system as

evidenced by her parents and guardian/s is always there to support the patient
during the duration of the disease. It was noted that the patient’s recovery was
hasten by the security she get from her family members.

Page | 8
II. Mental Status

On The day of assessment, the patient was slightly disoriented as

evidenced by her non-matching statements (date of manifestations). But she was
able to mention her name, the time and place.

Norms:

The patient should be oriented to time and place, can identify past and
recent memories and should be able to verbalize concrete messages. The patient’s
ability to read and write should match his/her educational level. The patient
should be able to respond to questions and identify all the objects presented to
him/her. The patient should be able to evaluate and act appropriately in situations.
(Estez Health Assessment and Physical Examination 3rd Edition).

Interpretation:

On the day of assessment, the patient was oriented as to time and place.
Her ability to write matches her educational level. The patient also was able to
recall recent memories and respond to questions asked from her and was able to
identify persons surrounding her. However, some of her stories regarding onset of
symptoms slightly challenge each other.

III. Emotional Status

Patient X cooperated during the interview; however, some irritability was

noted. She was able to interact with the interviewer. When asked what she thinks
of her condition, she said that she will get over it fast enough and stated that she
will play again with her playmates as soon as she is discharged from the hospital.

Norms

Adolescence falls under the identity vs. confusion stage of development

where the main task is to have a concrete identity free from judgement of others.
Failure to achieve this task results usually to confusion. The main point in this
stage is identification of one’s own gender affinity.

Page | 9
Interpretation

Despite the patient’s young age, she was able to handle her emotions well.
The irritability shown by the patient was brought about by her present condition,
which was reduced as her recovery progresses.

IV. Sensory Perception

• Sense of Sight

With the use of a penlight the following were observed:

 Pupils constrict when struck by light

 Patient’s eyes are symmetrical and round

 Sclera is white in color

 Eyes move symmetrically.

Norms

The eyes must be symmetrical during the six cardinal gazes. The sclera
should be white with some small blood vessels. Papillary constriction should
occur when struck by light. (Health Assessment and Physical Examination, Mary
Ellen Zator Estez)

Interpretation

With the given data, the patient’s extra ocular muscle movements and
papillary responses were normal throughout the assessment period.

Sense of Taste

Page | 10
 On the day of the assessment, the sensation of the client’s taste was
impaired as evidenced by her inability to distinguish different tastes (i.e. sweet,
sour, salty, and bitter).

Norms

The mucus membrane covering the upper surface of the tongue has
numerous projections called papillae, which assist in handling food and contain
taste buds. Four qualities of taste are found in taste buds distributed over the
surface of the tongue: bitter is located at the base, sour along the sides, and salty
and sweet near the tip. (Estez Health Assessment and Physical Examination 3rd
Edition)

Interpretation

Due to the patient’s fever, her sense of taste was affected as evidenced by
her not being able to distinguish different qualities of tastes of the food that she
eats.

Sense of Hearing

Voice whisper test was used. At approximately three feet away from the
back of patient x, words were whispered and the patient x was instructed to repeat
the words that were whispered. The test was repeated on the other ear. The patient
was able to repeat the words whispered to her.

Norms

For the auditory acuity, the patient should be able to repeat the words
whispered from a distance of two feet. (Health Assessment and Physical
Examination, Mary Ellen Zator Estez)

Interpretation
Based from the given data, the patient’s auditory acuity was normal
throughout the assessment period.

Page | 11
Sense of Smell
The patient’s nose is at the midline of the face and is symmetrical. The
patient was able to identify the smells of the objects presented to her (i.e. orange
fruit).
Norms
Nose must be symmetrical and along the midline of the face. Each nostril
must be patent and can recognize the smell of an object (Health Assessment and
Physical Examination, Mary Ellen Zator Estez).
Interpretation
Based from the given data, the patient’s sense of smell was normal
throughout the assessment period.

Tactile Sensitivity

In the examination of the touch sensation of the patient, she was instructed
to close her eyes and tell what she feels when she was going to be pricked on her
palm. The patient responded and stated that the prick was painful.

Norms

The skin contains receptors for pain, touch, pressure and temperature.
Sensory signals that help determine precise locations on the skin are transmitted
along rapid sensory pathways, and less distinct signals such as pressure of poorly
localized touch are sent via slower sensory pathways. (Health Assessment and
Physical Examination, Mary Ellen Zator Estez)

Interpretation
The patient’s sensory transmission throughout the assessment functions
well as manifested by the data presented

V. Motor Stability and Gait

Page | 12
 On the day of the assessment, the patient appears weak, indicating that she
was advised to stay in bed and limit her movement.

Assessment for range of motion, which was done on the same day,
included the ability of the patient to move his shoulder apart. She also was able to
move her shoulders laterally and medially as well as rotate her shoulder in the
same manner. She was able to bend her elbows closer and farther apart or rotate it
laterally to face upward and extending beyond the neutral position.

The patient also was able to flex and extend his knees, dorsiflex and
plantar flex his ankles and feet, tilt her feet inward and move it toward and away
the midline of his body. Her neck was symmetrical with her head in central
position. Movements through full range of motion was done without any
discomfort.

Norms

Teenage people have enough eye-hand coordination to play physical

games. Most people of this age have sufficient motor control for activities such
as sewing, dancing, etc. Normal muscle strength allows for complete voluntary
range of motion against both gravity and moderate to full resistance. Muscle
strength is equal bilaterally. A healthy person can perform the different ROM
activities (Wong’s Essentials of Pediatric Nursing 7th edition; Health Assessment
and Physical Examination, Mary Ellen Zator Estez)

Walking is the most convenient way to travel short distances. Free joint
mobility and appropriate muscle force increases walking efficiency. As the body
moves forward, one limb typically provides support while the other limb is
advanced in preparation for its role as the support limb.

Interpretation
The patient’s gait was not assessed on the day of the assessment due to her
weakness.

VI. Body Temperature

Page | 13
 The patient’s skin was warm to touch during the assessment. The
following body temperatures were obtained:

Date Time Temperature (°C) Axilla

December 13, 2010 5:00pm 38.6 °C
7:00pm 38.4 °C

Norms

36.5 C to 37.5 ◦C is the normal body temperature via the axilla. (Kozier,
Seventh edition, Copyright 2004)

Interpretation
The patient experienced intermittent alteration in body temperature
ranging from 38.6 °C to 38.4 °C due to the pathogenesis of the disease.

VII. Respiratory Status

The following observations were noted on Patient X during the

assessment; Patient X had an increased respiratory rate with shallow breathing by
mouth.

The following respiratory rates were taken:

Date Time Respiratory Rate (cpm)

December 13, 2010 5:00pm 26 cpm
7:00pm 24 cpm

Norms

Normal respiratory rate for adolescents is 16 – 20 cpm. Average is 18.

Respirations should be regular in rhythm and depth. The normal depth of
respirations should be non-exaggerated and effortless. No adventitious lung
sounds should be heard. (Craven Hirnle Foundations of Nursing: Human Health
and Function, 4th Edition).

Interpretation

Page | 14
 Patient X exhibited rapid, shallow breathing as evidenced by the above
data due to increased metabolic rate brought about by fever.

VIII. Circulatory Status

Patient X’s capillary refill time was observed to be at three (3) seconds.
The patient exhibited full bounding pulse with regular intervals.

The following pulse rates were obtained:

Date Time Pulse Rate (cpm) via Radial

pulse
December 13, 2010 5:00pm 82bpm
7:00pm 80bpm

Norms

Normal cardiac rate for adolescents is 60 - 100 bpm. The normal systolic
blood pressure is 102/62. Normal capillary refill is 2-3 seconds. (Craven Hirnle
Fundamentals of Nursing: Human Health and Function)

Interpretation
Patient X has a normal pulse rate and capillary refill time as evidenced by
capillary refill time was observed to be at three (3) seconds. The patient exhibited
full bounding pulse with regular intervals.

IX. Nutritional Status

During the first day of assessment, the client was on DAT (Diet as
Tolerated) except for dark colored food. According to the patient, they usually eat
three times a day. She prefers to eat pork. She also stated that she doesn’t eat
vegetables much. She drinks 1500-2000 ml of water every day. Based on the
client’s chart, the client’s weight was 46.1 kg and her height was 4’11” (4 feet 11
in.) or 1.475 m. Her computed BMI was 21.15. She was having slight anorexia
and was able to eat only a few amount of foods, and was only able to consume 4-5
glasses of water.

Page | 15
Norms:
BMI Scale
Underweight: < 18.5
Normal weight: 18.5-24.9
Overweight: 25-29.9
Obesity: 30 or higher
(Kozier,2006)

Interpretation
Her computed BMI was 21.15 which falls under the normal range despite
her loss of appetite.

X. Elimination Status
During the day of the assessment, the patient stated that she passed black
tarry stool once earlier. According to the patient she urinates 6 times a day. She
also noted that there is no pain during her eliminations.

Norms:
The average daily output of an adult is 1,500 ml or less/day or
approximately 60 ml/hr. The ideal fecal pattern for adults is 2 times per days
or 5 – 6 times per week. The normanl color of feces is brown. A dark colored
stool indicates bleeding in the GI system (Estes Health Assessment and Physical
Examination, Third Edition)

Interpretation
The patient’s elimination pattern is normal except for the color of her
feces on the day of assessment, which indicates a possible GI bleeding which is
part of the normal pathophysiology of the disease.

XI. Reproductive Status

Page | 16
 Patient X refused to be assessed.

XII. Sleep-Rest Pattern

The patient had 8-10 hours of sleep each day prior to the onset of the
disease. She noted that at the day of confinement, she has difficulty catching her
sleep due to abdominal pain.

Norms

Sleep is a naturally occurring state of consciousness characterized by

decreased awareness and responsiveness to stimuli. Rest is a state where cognitive
and motor functions are decreased but the awareness of the environment is
maintained. Normal sleep patterns for school-aged children and adolescents are
decreased to 7 – 8 hours of sleep in relation to growth spurts and increased
activity patterns. (Craven Hirnle Fundamentals of Nursing: Human Health and
Function)

Analysis

On the day of assessment, patient’s sleep pattern was disturbed due to the
irritability brought about by abdominal pain.

XIII. State of Skin and Appendages

On the day of assessment, patient’s skin was warm, and has a flushed
appearance. The patient has scars on her lower extremities. Her hair is uniformly
distributed, texture is silky, no presence of dandruffs and lice, no lesions or
lacerations noted on the scalp.

Norms

Normal skin tones vary among races, depending on the production and
accumulation of melanin. Skin is normally warm .Normally, skin is dry to touch
but moisture can accumulate in the folds. Texture of unexposed skin is usually
smooth, has good elasticity and is free from lesions and wounds. Hair should be

Page | 17
 uniform in distribution, silky, no presence of dandruffs or ;esions and lice in the
scalp.(Fundamentals of Nursing, Barbara Kozier; 7th edition)

Interpretation
The patient’s skin was warm and flushed due increased metabolic demand
brought about by fever.

6. Diagnostic and Laboratory Procedures

Diagnostic/ Date Indication/s Result/s Normal Analysis and

Laboratory Ordered or Purposes Values Interpretation
Procedures and date (Units of results
Result/s used in
In the
Hospital)
Repeat December CBC provides
Complete 13, 2010 much
Blood Count information
(CBC) with about the
Prothrombin overall health
time and of the
APTT individual, it
is an essential
component of
a complete
physical
examination,
especially
when
performed on
admission to
a health-care
facility. It is
indicated for
suspected
hematologic
disorder,
neoplasm, or
immunologic
abnormality

Page | 18
WBC 3.0 4.8-10.8 Not Normal
> Decrease may
indicate changes
in WBC
production

Hgb 12.55 13-17 Not Normal

> Decrease
indicates
possible decrease
in oxygen
carrying action

Hct 44.10 40-52 Normal

> No indicative
abnormalities
noted

Plt 100 150-400 Decreased

> Decrease in
platelets may be
due to immature
megakaryocytes.

Neu 31.10 40-70 Normal

> No indicative
abnormalities
noted

Lym 70 19-48 Increased

> Increase in
lymphocytes
signifies the
activation of the
immune system
to combat the
foreign invaders

Eos 3.2 3-9 Normal

> No indicative
abnormalities
noted

Page | 19
RBC 4.79 4.7-6.1 Normal
> No indicative
abnormalities
noted

MCV 92 82-98 Normal

> No indicative
abnormalities
noted

MCH 30.19 28-33 Normal

> No indicative
abnormalities
noted

MCHC 33 33-36 Normal

> No indicative
abnormalities
noted

Mono 4.6 2-8 Normal

> No indicative
abnormalities
noted

Baso 5.2 0-5 Slightly

increased
> Increase in
basophils
signifies
activation of the
immune system
to combat the
foreign invaders.

NURSING RESPONSIBILITIES:

Before:

 Determine the clients understanding of the procedure

 Determine the clients response to previous testing

Page | 20
During:

 Ensure client’s comfort until the procedure will be done

After:

 Document the method of testing and results on the clients record

 Immediately reached the blood sample on the laboratory

 Follow-up result from laboratory

7. Anatomy and Physiology

Platelets, or thrombocytes are small, irregularly-shaped anuclear cell fragments.

which are derived from fragmentation of precursor megakaryocytes. The average
lifespan of a platelet is normally just 5 to 9 days. Platelets play a fundamental role in
hemostasis and are a natural source of growth factors. They circulate in the blood of
mammals and are involved in hemostasis, leading to the formation of blood clots. If the
number of platelets is too low, excessive bleeding can occur. However, if the number of
platelets is too high, blood clots can form (thrombosis), Platelets release a multitude of
growth factors including Platelet-derived growth factor (PDGF), a potent chemotactic
agent, and TGF beta, which stimulates the deposition of extracellular matrix. he
physiological range for platelets is 150-400 x 109 per litre.

Image from a light microscope (40x) from a peripheral blood smear surrounded by red
blood cells. One platelet can be seen in the upper left side of the image (purple) and is
significantly smaller in size than the red blood cells (stained pink) and the two
neutrophils (stained purple).

Page | 21
Wound repair
The blood clot is only a temporary solution to stop bleeding; vessel repair is therefore
needed. The aggregated platelets help this process by secreting chemicals that promote
the invasion of fibroblasts from surrounding connective tissue into the wounded area to
form a scar. The obstructing clot is slowly dissolved by the fibrinolytic enzyme, plasmin,
and the platelets are cleared by phagocytosis.

he megakaryocyte is a bone marrow cell responsible for the production of blood

thrombocytes (platelets), which are necessary for normal blood clotting. Megakaryocytes
normally account for 1 out of 10,000 bone marrow cells but can increase in number
nearly 10-fold in certain diseases

Lymphocyte
A lymphocyte is a type of white blood cell in the vertebrate immune system

Types of lymphocytes

A stained lymphocyte surrounded by red blood cells viewed using a light microscope.

The three major types of lymphocyte are T cells, B cells and natural killer (NK) cells.

Natural killer cells

NK cells are a part of innate immune system and play a major role in defending the host
from both tumors and virally infected cells. NK cells distinguish infected cells and
tumors from normal and uninfected cells by recognizing level changes of a surface
molecule called MHC (major histocompatibility complex) class I. NK cells are activated
in response to a family of cytokines called interferons. Activated NK cells release
cytotoxic (cell-killing) granules which then destroy the altered cells.[2] They were named
"natural killer cells" because of the initial notion that they do not require prior activation
in order to kill cells which are missing MHC class I.

Page | 22
T cells and B cells

T cells and B cells are the major cellular components of the adaptive immune response. T
cells are involved in cell-mediated immunity whereas B cells are primarily responsible
for humoral immunity (relating to antibodies). The function of T cells and B cells is to
recognize specific “non-self” antigens, during a process known as antigen presentation.
Once they have identified an invader, the cells generate specific responses that are
tailored to maximally eliminate specific pathogens or pathogen infected cells. B cells
respond to pathogens by producing large quantities of antibodies which then neutralize
foreign objects like bacteria and viruses. In response to pathogens some T cells, called T
helper cells, produce cytokines that direct the immune response while other T cells,
called cytotoxic T cells, produce toxic granules that induce the death of pathogen infected
cells. Following activation, B cells and T cells leave a lasting legacy of the antigens they
have encountered, in the form of memory cells. Throughout the lifetime of an animal
these memory cells will “remember” each specific pathogen encountered, and are able to
mount a strong response if the pathogen is detected again.

Page | 23
 8. Pathophysiology (Book Based)

MODIFIABLE RISK FACTORS: NON-MODIFIABLE RISK

1. Presence of stagnant water or FACTORS:
other places conducive for 1. Age - More common in children
mosquito breeding less than 15 years of age
2. Initial dengue virus infection 2. Sex –More common in females
from a specific subtype of virus 3. Race – More common in
potentiates the response of body to Caucasians
the second dengue virus infection
by a different subtype of virus

Dengue virus implantation via mosquito bite in skin to

the bloodstream (Flavivirus 1,2,3,4)

Infection and Replication of virus at Macrophages that will

initiate body’s innate immune response (non-specific response)

Dengue Fever

Antibodies are produced that adheres to the antigen to

disable the viruses and form antibody-antigen complexes

Memory Cells advocate immunity to

specific serotype of dengue virus

Second infection from a different serotype of dengue virus attach to

macrophages as the body recognizes them as if it was the first subtype

Massive and continuous release of Immune Adherence to platelets Affectation of Megakaryocyte

cytokines, histamine, and prostaglandins
As the virus is still not deactivated

Increased Metabolic Demand Increased capillary permeability Decreased platelet count due to increased
and Body Temperature that would lead to extravasations destruction and decreased production with
of plasma increased bleeding tendencies

Fever Appearance of petechiae

Nausea and Anorexia Hypovolemic
Headache Epistaxis, Gum Bleeding, GI Shock
Myalgia Bleeding, Black Tarry Stools
Retro-orbital pain
Page | 24
(Patient-Based)

MODIFIABLE RISK FACTORS: NON-MODIFIABLE RISK

1. Presence of stagnant water or FACTORS:
other places conducive for 1. Age - More common in children
mosquito breeding less than 15 years of age

Dengue virus implantation via mosquito bite in skin to

the bloodstream (Flavivirus 1,2,3,4)

Infection and Replication of virus at Macrophages that will

initiate body’s innate immune response (non-specific response)

Dengue Fever

Antibodies are produced that adheres to the antigen to

disable the viruses and form antibody-antigen complexes

Memory Cells advocate immunity to

specific serotype of dengue virus

Second infection from a different serotype of dengue virus attach to

macrophages as the body recognizes them as if it was the first subtype

Massive and continuous release of Immune Adherence to platelets Affectation of Megakaryocyte

cytokines, histamine, and prostaglandins
As the virus is still not deactivated

Increased Metabolic Demand

and Body Temperature Decreased platelet count due to increased
destruction and decreased production with
increased bleeding tendencies
Fever
Nausea and Anorexia
Headache
Myalgia
Retro-orbital pain Epistaxis, Black Tarry Stools

Page | 25
 i. Nursing Care Plan

December 13, 2010

EXPECTED
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE
OUTCOME
S> O Risk for fluid Within 2 hours of > Monitor vital > Hypotension The patient will
volume deficit appropriate signs. may indicate identify and
O> with previous related to nursing shock. demonstrate ways
episode of hemorrhage (due intervention, the > Monitor CBC and > Low platelet to prevent further
epistaxis to low platelet patient will platelet count. count signifies bleeding after 2
> presence of count) identify and patient is at risk for hours of
rashes in demonstrate ways > Instruct patient to bleeding. appropriate
extremeties Scientific to prevent further use soft bristle > To prevent nursing
> dry mucous Explanation: bleeding. toothbrush bleeding of gums intervention.
membrane Low platelet count > Emphasize the
> with black tarry increases the importance of >To hydrate the
stool patient in increasing fluid patient.
> laboratory results developing intake.
reveal low platelet bleeding. > Instruct client to
count: 93 Hemorrhage can avoid dark colored > Dark colored
lead to foods. food produces dark
hypovolemic colored stools
shock. which signify
> Teach patient in upper GI bleeding.
managing epistaxis > Cold compress
by applying ice promotes
pack above the vasoconstriction.
bridge of the nose.
> Advise the patient
not to take aspirin > Aspirin prevents
in times of fever. coagulation and it
is a GI irritant.

Page | 26
 EXPECTED
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE
OUTCOME
S> “Hindi ako Altered comfort Within 4 hours of > Position patient > To promote The patient will
mapakali dahil sa related to presence nursing on maximal relaxation verbalize feelings
mga butlig sa of maculopapular intervention, the comfort. > To promote and demonstrate
katawan ko. rash in the skin. patient will > promote cooling comfort ways to improve
verbalize feelings of the skin by comfort after 4
O> presence of Scientific and demonstrate providing TSB > To reduce hours of nursing
rashes in Explanation: ways to improve > Encourage anxiety. intervention.
exrremeties Since there is comfort. verbalization of
> frequent invasion in the feelings
positioning bloodstream it > Advise patient not > To prevent
> frequent would create an to scratch the skin. scratching
scratching in the inflammatory
skin observed response in the
>irritable skin by producing
maculopapular
rashes. The rashes
were characterized
as reddened, warm
and itchy.

Page | 27
 EXPECTED
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE
OUTCOME
S>” Hindi ako Activity Within 3 hours of > Assess patient >Depression, Within 3 hours of
makatayo at hinang intolerance related appropriate emotional and stress might be a appropriate
hina ako” to generalized nursing psychological result of inactivity. nursing
body weakness interventions, the factors that affect interventions, the
O> pale patient will her current patient wouldl
>weak in Scientific verbalize measure condition. >To provide verbalize measure
appearance Explanation: on how to >Position the relaxation. on how to
> frequent Dengue conserve energy patient in conserve energy
positioning hemorrhagic fever and will comfortable >To conserve and wouldl
>irritable causes body demonstrate position. energy. demonstrate
>BP 100/60mmHg malaise or simple bedside >Advice the patient simple bedside
>pale weakness which activities. to take a rest . >To provide activities.
decreases the >Minimize relaxation.
patient ability to environmental
tolerate activity stimuli. >to minimize
>Keep the unnecessary
frequently used movement and to
thing within the conserve energy.
reach. >To prevent injury
and to conserve
>Assist the patient energy.
in doing activity
such as when sitting
and moving out of
bed.
>The following are >To avoid muscle
encourage to the atony.
patient: >To conserve
• To do passive energy.
range of motion.
• Have rest between >To provide

Page | 28
 activity adequate
• Have a small but Caloric intake.
frequent feeding. >To provide
• Eat food high in energy and boost
calorie and rich in immune system.
vitamin C > Dark colored
• Avoid dark food produces dark
colored food such colored stools
as chocolate and which signify
food rich in iron. upper GI bleeding.

Page | 29
 ii. Implementation

1. Medical Management

i. IVF’s, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy etc.

Medical Date Ordered/ General Indication/s, Client's

Management/ Date Taken/ Description Purpose/s reaction to
Treatment Given the treatment
Date Changed/
Date
Discontinued
IV Therapy Started on IV Therapy is the IV Therapy is The patient
December 13, giving of liquid usually performed did not
1L PLRS 2010 directly into a vein. for fluid volume reported pain
(isotonic) maintenance, in the IV site
regulated at 40 fluid volume
gtts/min replacement,
medication
administration,
blood
administration,
total parenteral
nutrition and
serves as an
emergency line
Prior:

> understand why the therapy is needed.

> determine potential outcomes for the client

> understand the fluid and electrolyte and acid base status of the client

> provide an explanation to the client and gain cooperation

> select the appropriate IV set

Page | 30
During:

> assess the following:

a. right intravenous fluids infusing

b. right intravenous fluids for the client

c. date on the tubing

d. right rate according to the rate prescribed and the clients condition

e. absence of kinks in the tubing that could result in occlusion of the fluid flow

f. date on the intravenous access device

g. insertion site and vein access for evidence of pain, redness, warmth, or
coolness, and swelling

After:

> discard the administration set accordingly

>document relevant data.

Page | 31
 ii. Drugs
Name/s of Date Route of Mechanism Indication/s Client's
drugs(generi ordered/ administratio Of action , Purpose/s response to
c and brand Date n & dosage & medication
name) Taken/Given frequency of s with
, Date administratio actual side
changed/ n effect
D/C
Generic December 13, 500 mg tab May produce Mild pain or The client
Name: 2010 every 4 hours analgesic fever. did not have
PO effect by any adverse
Paracetamol blocking reaction
pain from the
impulses by drugs.
inhibiting
prostaglandi
n or pain
receptor
sensitizers.
May relieve
fever by
acting in
hypothalami
c heat-
regulating
center.

Nursing Responsibilities

Before:

• Check the physician’s order.

• Assess patient’s temperature or pain before and during the therapy.
• Assess patient’s and family’s knowledge of drug therapy.

During:

• Tell patient to use drug if the body temperature is greater than or equal to 37.8
degree Celsius.

Page | 32
After:

• Monitor for any adverse reaction.

• Warn patient that high doses or unsupervised long-term use can cause liver
damage.
Name/s of Date Route of Mechanis Indication/s, Client's
drugs(generi ordered/ administratio m Of Purpose/s response to
c and brand Date n & dosage & action medication
name) Taken/Given frequency of s with
, Date administratio actual side
changed/ n effect
D/C
Generic December 13, 1 gm tab every May adhere Therapy for The client
Name: 2010 8 hours PO to and gastrointestina did not have
protect l bleeding. any adverse
Sucralfate ulcer’s reaction
surface by from the
forming drugs.
barrier.

Nursing Responsibilities

Before:

• Check the physician’s order.

• Assess patient’s GI symptoms before starting therapy and regularly thereafter to
monitor the drug effectiveness.
• Assess patient’s and family’s knowledge of drug therapy.

During:

• Instruct patient to take drug one hour before each meal and bedside.

Page | 33
After:

• Monitor for any adverse reaction.

• Monitor patient for severe, persistent constipation.
• Tell patient to continue on prescribed regimen to ensure complte healing.
• Urge patient to avoid cigarette smoking, alcohol, chocolate and spicy foods.
• Tell patient to sleep with head of bed elevated.
• Tell patient to avoid large meals within two hours of bedtime.
• Be alert for adverse reactions and drug interaction.

iii. Diet

TYPE OF DATE GENERAL INDICATION/S SPECIFIC CLIENT’ S

DIET ORDERED, DESCRIPTION PURPOSE/S FOODS RESPONSE
DATE TAKEN AND/OR
STARTED, RESPONSE
DATE TO THE
CHANGED DIET
Diet As December The patient can To increase rate Rice The client
Tolerated 13, 2010 eat any food as of healing Fish did not
(DAT) long as tolerated Fruits exhibit any
with while avoiding Gelatin allergic
Avoidance dark colored Crackers reactions to
of dark foods which may the food
colored alter the taken.
foods. laboratory
procedures.

Nursing Responsibilities (DAT with dark-colored foods avoidance)

Prior to the Procedure

 Caution patient to avoid food such as eggs, nuts, milk, sulfites, fish and
chocolate that can trigger asthma attack.

During the Procedure

Page | 34
  Advise client to properly chew the food.

After the Procedure

 Advise patient to report any allergic reaction to the food taken.

iii. Exercise
i. Activity / Exercise
TYPE OF DATE GENERAL INDICATION/S CLIENT’S
EXERCISE ORDERED DESCRIPTION RESPONSE/
DATE TO THE
STARTED EXERCISE
DATE
CHANGED
AROM December A body action involving These exercises The client
(Active 13, 2010 the muscles, joints, and reduce stiffness participated
Range of natural movements such as and help keep in the
Motion) abduction, adduction, your joints activity.
with flexion, extension, flexible.
bleeding pronation, supination, and
precaution. rotation.

Page | 35
 3. Nursing Management
December 13, 2010

SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING INTERVENTION EVALUATION

S> O O> with previous Risk for fluid Within 2 hours of > Monitored vital Goal partially met.
episode of volume deficit appropriate signs. The patient able to
epistaxis related to nursing identify and
> presence of hemorrhage (due intervention, the > Monitored CBC demonstrate ways
rashes to low platelet patient will and platelet count. to prevent further
> dry mucous count) identify and bleeding after 2
membrane demonstrate ways > Instructed patient hours of
> with black tarry to prevent further to use soft bristle appropriate nursing
stool bleeding. toothbrush intervention.
> laboratory
results reveal low > Emphasized the
platelet count: 93 importance of
increasing fluid
intake.

> Instructed client

to avoid dark
colored foods.

> Taught patient in

managing epistaxis
by applying ice
pack above the
bridge of the nose.

> Advised the

patient not to take
aspirin in times of
fever.

Page | 36
 SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING INTERVENTION EVALUATION
S> “Hindi ako O> presence of Altered comfort Within 4 hours of >Positioned patient Goal partially met.
mapakali dahil sa rashes related to presence nursing on maximal The patient able to
mga butlig sa > frequent of maculopapular intervention, the comfort. verbalize feelings
katawan ko. positioning rash in the skin. patient will and demonstrate
> frequent verbalize feelings > promoted cooling ways to improve
scratching in the and demonstrate of the skin by comfort after 4
skin observed ways to improve providing TSB hours of nursing
>irritable comfort. intervention.
> Encouraged
verbalization of
feelings

> Advised patient

not to scratch the
skin.

Page | 37
 SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING INTERVENTION EVALUATION
S>” Hindi ako O> pale Activity Within 3 hours of > Assessed the Within 3 hours of
makatayo hinang >weak in intolerance related appropriate patient emotional appropriate nursing
hina ako” appearance to generalized nursing and psychological interventions, the
> frequent body weakness interventions, the factors that affect patient was able to
positioning patient will her current verbalize measure
>irritable Scientific verbalize measure condition. on how to conserve
>BP Explanation: on how to >Positioned the energy and
100/60mmHg Dengue conserve energy patient in demonstrated
hemorrhagic fever and will comfortable simple bedside
causes body demonstrate position. activities such as
malaise or simple bedside >Adviced the the patient was
weakness which activities. patient to take a rest able to sit on bed.
decreases the .
patient ability to >Minimized
tolerate activity environmental
stimuli.
>Kept the
frequently used
thing within the
reach.

>Assisted the
patient in doing
activity such as
when sitting and
moving out of bed.
>The following are
encouraged to the
patient:
• To do passive

Page | 38
 range of motion.
• Have rest between
activity
• Have a small but
frequent feeding.
• Eat food high in
calorie and rich in
vitamin C
• Avoid dark
colored food such
as chocolate and
food rich in iron.

Page | 39
 J. EVALUATION

1. Patient’s Daily Program in the Hospital

Daily Program Tuesday Wednesday Thursday

April 13, 2010 April 14, 2010 April 15,
2010
Nursing Problems
1.Risk for fluid volume deficit
related to hemorrhage (due to low Identified and
platelet count) Resolved

2. Altered comfort related to

presence of maculopapular rash in Identified and
the skin. Resolved

3. Activity intolerance related to Identified Resolved

generalized body weakness

Vital signs T: 36.20C T: 37.90C T:36.50C

( 6 pm) PR: 65bpm PR: 106bpm PR:720C
(see 13 areas of assessment ) RR: 17cpm RR: 37cpm RR:200C
Diagnostic & Lab. Procedures CBC
> Decrease platelet
count (100)

Medical and Surgical Mgt. IV Therapy Discontinued

IV Therapy PLRS 1L@ 41 –
PLRS 1L @ 41 – 42 42 µgtts/min.
µgtts/min.
On-going

Drugs Paracetamol Paracetamol

Sucralfate Sucrofate Paracetamol
Sucrofate

Diet DAT (avoid dark- Same Same

colored food

Page | 40
 Activity/ Exercise Bed Rest AROM (bleeding AROM
precaution) (bleeding
precaution)

2. Discharge Planning

i. General condition of the client upon discharge

The patient’s general condition upon the supposed discharge date indicates
an improved condition. There are normal vital signs, no limited movements,
absent bleeding signs, no indication of weakness, verbalized feeling of comfort,
almost unnoticeable itchiness. Furthermore, the patient was able to roam the
hospital premises without assistance, and was no cheerful compared to the 1st day
of assessment. The doctor is only waiting for the result of her latest blood
chemistry to decide wheter she could be discharged or needed more medical
treatment.

ii. METHOD approach

The following is a discharge plan that is needed to be implemented by the client with the
help of hir significant others.

MEDICATIONS EXERCISE TREATMENT HEALTH OPD DIET

TEACHINGS FOLLOW-
UP
Vitamin C Active N/A >Increased N/A >High
supplements- Range of fluid intake Vitamin C
should be taken Motion >Increase (Citrus
more preferably (bleeding intake of food Fruits)
in the morning precautiono rich in Vitamin >High
after breakfast n few days C protein
with adequate after >Proper foods
water. discharge) enveronmental (fish,meats,e
Walking sanitation ggs,milk)
>proper over- >High
all hygiene Carbohydrat
technique e (grain
products,
bead, corn,
sweet
potato)

Page | 41
Note: This METHOD approach was accomplished by the group even though the patient
was not discharged yet in order to make this case study as complete and as
comprehensive as possible. Actual results will definitely vary.

XIV. CONCLUSION

After the group have done all there has to do in the management of their
chosen case study, where they were able to meet all their imposed objectives at
the start of the treatments, they had acquired new skills, developed their clinical
competencies, and gathered first hand empirical data of the pathogenesis and
treatment of the disease. This case made the group more familiar about the things
related to Dengue Hemorrhagic Fever. The group was also able to apply the
appropriate interventions needed by the patient. With the group’s proper
explanations, the client’s guardian now fully understands what her child’s
condition is and why it is crucial that strict monitoring is needed.

XV. RECOMMENDATION

As the patient was about to be discharged, the group recommended the

following health teachings to the client:

 Adequate rest

 Advised patient to have adequate sleep (6-8 hours).

 Refrain doing strenuous activities like playing outdoor games that are
tiring.

 Advised client to consume foods rich in vitamin C

 Advised client’s mother to give her child’s medications regularly., and

avoiding aspirins

 Improve or maintain the cleanliness in their surroundings, especially the

possible breeding sites of mosquitoes

For the future researchers, the group recommends the following to:

 Use appropriate assessment techniques to come up with a good assessment

 Formulate a comprehensive health history

Page | 42
  Make a comprehensive Pathophysiology of the condition

 Develop good nursing care plans that are patient – oriented

Related Literatures

Current Research:

1. Comparison of Plaque- and Flow Cytometry-Based Methods for Measuring

Dengue Virus Neutralization

Research and development in the field of Dengue vaccines is ongoing and as the vaccines
enter clinical trials neutralization has to be measured quantitatively, rapidly and
accurately. These researchers and scientists have developed methods to generate results
that are similar to plaque reduction, already established, by using flow-based
neutralization assays. The flow-based assays are an improvement over the established
method because they utilize human cells and permit for high-throughput screening.

2. Molecular epidemiology of dengue type 2 virus in Venezuela: evidence for in situ

virus evolution and recombination

This research shows that the Dengue Fever outbreak in 1978 and the Dengue
Hemorrhagic Fever in 1989 in Venezuela have ties to the Asian strain of the virus. The
virus currently present in Venezuela has evolved in-situ.

3. Chest Radiographic Presentation in Patients with Dengue Hemorrhagic Fever

A retrospective study was performed on 363 DHF patients from southern Taiwan. After
reviewing 468 CXRs more than half showed abnormalities after 3 days. The major
findings of the review were pleural effusions and infiltration. During the first week
abnormalities were presented and during the second week recovery was evident.
Correlations were found in between the CXRs and laboratory results and ultimate
outcome of the patient’s condition. This research shows that the CXR may be an
utilizable tool in evaluating DHF and must be done in the first week after the illness
presents itself.

Bibliography

www.wikipedia.com

www.medscape.com

www.doh.com

Page | 43