Dengue (Print)

8/2/2019 Dengue (Print)

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Eiselle G. San Diego

Case Presentation: DHF II with warning sign

I. INTRODUCTION:

A. Dengue Fever

Dengue fever is an acute febrile disease caused by infection with one of the serotypes of dengue virus

which is transmitted by mosquito genus Aedes egyptis.

B. Etiology

1. Flaviviruses 1, 2, 3, 4, a family of Togaviridae are small viruses that contain single strand RNA.

2. Arboviruses group B

C. Incidence

1. Age – dengue fever may occur at any stage, but is more common among children and peak between 4

to 9 years old.2. Sex – both sexes can be affected.

3. Season – it is more frequent during the rainy season.

4. Location – dengue fever is more prevalent in urban communities.

D. Clinical Manifestations:

A. Dengue fever

1. Prodromal symptoms characterized by:

a. Malaise and anorexia up to 12 hours

b. Fever and chills accompanied by several frontal headache, ocular pain, myalgia with severe

backache, and arthralgia.

2. Nausea and vomiting3. Fever is non-remitting and persist for 3 days to 7 days.

4. Rash is more prominent on the extremities and the trunk. It may involve the face in some

isolated cases.

5. Petechiae usually appears near the end of the febrile period and most common on the lower

extremities.

B. Dengue Hemorrhagic Fever (DHF)

This severe form of dengue virus infection manifested by fever, hemorrhagic diathesis, hepatomegaly and

hypovolemic shock.

Phases of the Illness1. Initial febrile phase lasting from two to three days.

a. Fever (39-40 degree C) accompanied by headache

b. Febrile convulsion may appear

c. Palms and sole are usually f lushed

d. Positive tourniquet test

e. Anorexia, vomiting, myalgia



f. Maculopapular or petechial rash maybe present that usually starts in the distal portain of the

extremities (sparing the axilla and chest), the skin appears purple with blanched areas with

varied sizes, the Herman’s sign known as the pathognomonic sto the disease.

g. Generalized or abdominal pain

h. Hemorrhagic manifestation like positive tourniquet test, purpura, epixtasis, and gum bleeding

maybe present.

2. Circulatory phase

a. There is a fall of temperature accompanied by profound circulatory changes on the 3rd

to 5th

day

b. Patient becomes restless, with cool clammy skin.

c. Cyanosis is present

d. Profound thrombocytopenia accompanies the onset of the shock

e. Bleeding diathesis may become more severe with GIT hemorrhage.

f. Shock may occur due to loss of plasma from the intravascular spaces and hemoconcentration

with markedly elevated hematocrit is present.

g. Pulse is rapid and weak; pulse pressure becomes narrow and blood pressure may drop to an

unobtainable levelh. Untreated shock may result to comma, metabolic acidosis and death may occur within 2 days.

i. With effective therapy, recovery may follow in 2 to 3 days.

Classification According to Severity

( Halstead & Nimmanitya)

Grade I

- There is fever accompanied with non-specific constitutional symptoms and the only

hemorrhagic manifestation is positive (+) tourniquet test.

Grade II

- All signs of Grade I plus spontaneous bleeding from the nose, gums, GIT are present.

Grade III

- There is presence of circulatory failure as manifested by weak pulse, narrow pulse pressure,

hypotension, cold clammy skin and restlessness.

Grade IV

- There is profound shock, undetectable blood pressure and pulse.

II. PATIENT PROFILE

A. Patient data

Patient is 6 years old male suffering from fever ( 40 degree C) for 3 days, headache, vomit for 5 times on

the 3rd

day, weakness, weight loss and abdominal pain. The mother decided to bring her son to SLH

because she saw her son’s nose bleeding.



B. Nursing history

a. Chief complaint: nose bleed

b. Past health history

- According to the mother her son was not always sick like other children. His son only have

fever, and flu even when his son is still baby.

c. Personal and social history

- According to the patient mother his son was in grade 1 studying in tayuman and have twin

brother. The mother does not work and his husband is working as an electrician. His son

plays a lot in school and at home. They are residing in Tayuman with there relatives in 1

compound. His son is not picky on choosing food to eat even it is vegetable or fish.

d. Developmental history

- The patient is 6 years old. He answered congruent to my question with eye contact.

Currently grade 1 studying in Tayuman. His age is appropriate to his grade level in school.

The patient can read, write and name the object around him.

e. Immunization

- According to the patient mother her son has a complete immunization.

f. Physical examination:

- The patient vomit 5x before arriving in the hospital. Has headache, loss appetite, weak, loss

weight, and abdominal pain is present.

C. Course in the ward:

- Vital signs every 4 hours

- Keep patient at rest during bleeding episodes.- Analgesic drugs other than aspirin is require for the relief oh headache, ocular pain, and

myalgia.

- For the initial phase intravenous infusion is given for prevention of dehydration and plasma

replacement.

- For nose bleed, patient is positioned with trunk elevated and applying ice bag to the bridge

of nose and to the forehead is advised.

- For the restoration of blood volume the patient is pos ition in trendelenberg to provide

greater volume to the head part.



III. PATHOGENESIS AND PATHOLOGY

1. Infectious virus is deposited in the skin by the vector and initial replication occurs at the site of the

infection and in local lymphatic tissues.

2. Within few days, viremia occurs, lasting until 4th

or 5th

day onset of symptoms.

3. Evidence indicates that macrophages are the principal site of replication.

4. At the site of petechial rash, non-specific changes are noted which include endothelial swelling,

perivascular edema, and extravasation of blood.

5. There is marked increase in vascular permeability, hypotension, hemoconcentration, thrombocytopenia,

with increased platelet agglutinability and or moderate disseminated intravascular coagulation.

6. The most serious resulting from increased permeability of the vascular endothelium and loss of plasma

from the intravascular space.



PATHOPHYSIOLOGY:

THOPHYSIOLOGY:Pedisposing

Geographical area- tropical islands in the

Pacific (Philippines) and Asia.

Precipitating

Environmental conditions (open spaces with water pots, and

plants)

Immunocompromise

Mosquito carrying dengue virus

Soldier

Sweaty skin

Aedes aegypt (dengue virus carrier). 8-12 days

of viral replication on mosquitos’ salivary

Bite from mosquito (Portal of Entry in the skin)

Allowing dengue virus to be inoculated

towards the circulation/blood (incubation

Period: 3-14 days)

Redness & itchiness in

the area

Virus disseminated rapidly into the blood and

stimulate WBC’s including B lymphocytes that

produces and secretes Immunoglibulins

(antibodies), and monocvtes/macrophages,

neutrophils.

Diagnostics:

Hermatology:

Increased WBC:

12, 900/cumm

(5, 000 – 10,

000/cumm)

Increased

Lymphocytes: 49%

(20-40%)

Antibodies attach to the viral antiges, and

then monocytes/macrophages will

perform phatocytosis through Fc receptor

(FcR) within the cells and dengue virus

replicates in the cells

Diagnostic:

Hematology:

Decreased Monocytes: 4%

(8-14%)

Decreased Neutrophils:

49% (50-70%)



Entry to

the bon

Entry to the

spleen, and

Recognition of dengue viral antigen on infected

monocyte

Release of cytokines which consist of vasoactive

agents such as interleukins , tumor necrosis factor,

urokinase and platelet activating factors which

stimulates WBCs and pyrogen release.

Dengue

Signs/ symptoms:

Febrile : 38.6C

Diaphoresis, warm skin,

flushed: headache of 3/10

pain scale; whitish spots; body

weakness

Virus ultimately targets liver and spleen parenchymal

cells where infection produces

Cellular direct destruction and infection of red bone

marrow precursor cells as well as immunological

shortened platelet

ThrombocytopeniaHepatosplenomegaly

Signs/ Symptoms:

Red sclera in both eyes

Petechiae

Signs/ symptoms:

Abdominal pain with 5/10

pain scale as verbalized



Diagnostics:

Ultrasound minimal

hepatosplenomegaly

Blood Chemistry:

SGOT: 558.0

U/L(Up to 46)

Diagnostic:

Hematology:

Decreased platelet:

68 00 cumm

Dengue Hemorrhagic

Increase number and size of the pores in the capillaries wh

leads to a leakage of fluid from the blood to the the

interstitial fluid (capillary leakage) of the different

Signs/ symptoms:

+1 Bipedal edema: weak

bound in a pulse

Recovery

Complications:

Metabolic acidosis

Hyperkalemia

Tissue anorexia

Hemorrhage into the CNS

Uterine bleeding may occur



IV. LABORATORY EXAMINATION:

DATE: January 26, 2012 January 30, 2012 NORMAL VALUES

WBC 3.55 7.98 4.8 – 10.8

RBC 4.57 3.88 M: 4.5 – 5.9

HEMOGLOBIN 124 107.2 M: 140 -175

HEMATOCRIT .392 .331 .414 - .504PLATELET 110 96 150 - 400

V. DRUG STUDY:

Brand name Classificati

on

Action Indication Contraindicatio

n

Side effect Nursing

Responsibilities

Paracetamol Analgesic,

muscle

relaxant

Decrease fever

by inhibiting

the side

effects of

pyrogens onthe

hypothalamic

heat

regulating

centers and by

a

hypothalamic

action leading

to sweating

and

vasodilation.

Relieves pain

by inhibitingprostaglandin

synthesis at

the CNS but

does not have

anti-

inflammatory

act on

beacause of its

minimal side

effect of

peripheral

prostaglandinsynthesis.

Relief to

mild to

moderate

pain

treatment of fever.

Hypersensitivity

intolerance to

tartazine

Stimulation,

drowsiness,

nausea, vomiting,

abdominal pain,

hepatotoxicity,hepatic seizure

(overdose), renal

failure ( high

prolonged

doses),

leukopenia,

neutropenia,

hemolytic

anemia,

thrombocytopeni

a, rash, urticarial,

hypersensitivity,

cyanosis, anemia,neutropenia,

jaundice,

pancytopenia,

CNS stimulation,

delirium followed

by vascular

collapse,

convulsion,

coma, death

Advice patient

to avoid taking

more than one

product

containingparacetamol at

one time; as

this may cause

toxicity if taken

concurrently.

Advise patient

to avoid

alcohol; acute

poisoning with

liver damage

may result;

acute toxicityincludes

symptoms at

nausea,

vomiting, and

abdominal pain;

physician

should be

notified

immediately.

Teach the

patient torecognize signs

of chronic

overdose;

bleeding,

bruising,

malaise, fever,

sore throat.



Inform the

patient that

urine may

become dark

brown as a

result of

phenacelin(metabolite of

acetaminophen

)

Tell patient to

notify prescribe

for pain or fever

lasting for more

than 3 days.

VI. NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:

“ Pauwi na kami

ng anak ko ano

ano ba mga

pede nyang

kainin pag uwi

namin?”

Objective:

AlertConscious

Self assisted

Consume

adequate food

Dried skin

Thin

Vital signs as

follows:

T: 36.2 degree C

P: 90 bpm

R: 14 bpm

BP: 100/70 mm

Hg

Readiness to

enhance

Nutrition

After 30 minutes

of health

teaching the

patient

significant

others will able

to express

knowledge of

healthy food

and fluid choiceto enhance

nutrition.

Assess eating

patterns and

food/ fluid

choices in

relationship to

any health risks

factor and

health goal.

Verify that agerelated and

developmental

needs are met.

Encourage

client’s

beneficial eating

pattern ( eg.

Following

dietary

program).

Discuss use of

nutritional

supplements,

OTC/ herbal

products.

Help to identify

specific

strengths and

weakness that

can be address.

These factorsare constantly

present

throughout life

span, although

differing for

each age group.

Positive

feedback

promotes

continuation of

healthy lifestyle

habits and new

behavior.

Confusion may

exist regarding

the need for/

use of these

products in

After 30 mins.

Of health

teaching the

patients

significant

others are able

to respond or

express

knowledge of

healthy foodand fluid choice

to enhance

nutrition.



balanced dietary

regimen.

VII. Discharge Planning

Discuss about a mosquito free environment to avoid further transmission of infection.

Eliminate the vector by:

- Changing water and scrubbing sides of flower vases once a week

- Destroy the breeding place of mosquitos by cleaning the surroundings

- Keeping the water containers covered

- Avoiding too many hanging clothes inside the house

Discuss about eating nutritios food and fluids.

Follow up check up.

Adequate rest

Personal hygiene

Dengue (Print)

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