236750009 dengue-case-study1

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University of Makati
College of
Nursing
J.P. Rizal Extension, West Rembo Makati City
A Case Study on
Dengue Hemorrhagic Fever
In partial fulfillment of the requirements in
Maternal and Child Nursing 2

Submitted to
Professor Kathlyn Elizabeth Santiago
Submitted by
Johnson Baingan
Catherine Calimlim
Janice Pola Congzon
Ma. Theresa Dimaculangan
Dean Fornea
Erlyn Regondon
Ronaldo Zamora
September 2008
A C K N O W L E D G M E N T
First of all, we would like to thank the Almighty God for the enlightenment
and strength He has bestowed on us in doing this case study.
We would like to acknowledge the following people:
To Ms. Kathleen Elizabeth Santiago for being one of our mentors;
To Mr. Edgar Clariz, for allowing us to review the medical records of our
patient; and
To our group, for the effort and a job well done!

TABLE OF CONTENTS
I INTRODUCTION..................................................................1
II OBJECTIVE........................................................................4
III ANATOMY AND PHYSIOLOGY................................................5
IV DENGUE AND DENGUE HEMORRHAGIC FEVER......................10
V PATHOPHYSIOLOGY..........................................................16
VI COMPREHENSIVE HEALTH HISTORY....................................27
VII PHYSICAL ASSESSMENT....................................................29
VIII DIAGNOSTICS AND LABORATORY EXAMS.............................32
IX MEDICAL MANAGEMENT.....................................................42
X COURSE IN THE WARD …………………………………………………………… 44
XI DRUG ANALYSIS...............................................................46
XII NURSING CARE PLAN........................................................49
XIII HEALTH TEACHING...........................................................58

I. INTRODUCTION
Dengue infection is one of the most common mosquito borne viral diseases of
public health significance. It has been identified as a clinical entity since
1780. Dengue is found in tropical and sub-tropical regions around the world,
predominantly in urban and semi-urban areas. Dengue hemorrhagic 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 where in age
groups that are predominantly affected are the preschool and school age.
This is a case of a 3 year-old male with Dengue Hemorrhagic Fever Category
II. Patient X is a toddler, admitted into the hospital around 5:00 am carried
by his mother. He is crying, looks weak and was not able to sleep well prior
to his admission, having eyebags are evidence of his restlessness. His
mother had told to the nurse that his child had already vomited three times
before he was brought to the hospital.
Doctors have diagnosed Patient X with DHF II with accompanying acute
tonsilopharyngitis. The patient tonsils were reddened and slightly inflamed
due to his tonsilphayringitis with a high fever measuring 40.5 o
C. Patient’s
breath sounds were clear and no signs of dehydration as evidence by good
skin turgor. Rashes were not present on either extremities or on his body
area.
To support the doctors diagnosis of Dengue, his Attending Physician ordered
complete blood count, platelet count, blood typing, stool examination and
urinalysis. At this time the patient was already on IVF as part of his fluid

replacement therapy since he had vomited three times before his admission
and this also serve as his initial treatment to his diagnosis.
Patient X temperature was closely monitored during his 6 day stay in the
hospital. His first 3 days was a period of high-fever, a classic symptom of
Dengue Fever in its Febrile stage. On his first day, the patient had a
convulsive state due to his elevated fever. Frequent tepid sponge bath were
given to him, two to four times in an eight hour shift, in conjunction with his
anti-pyretic drug medication to relieve him from his discomfort brought by
his high temperature. Anti-biotics was also part of his medication to treat his
tonsilopharyngitis. Within his first three day stay, patient is irritable most of
time, restless and crying. Patient X seldom ate the foods served to him. On
his fourth day, a significant drop in his temperature was noted, as low as
36.8 o
C which is a sign that the patient is entering into the toxic stage of
Dengue Fever. This state of defervescence, is a period where the number of
patient’s platelet is at its lowest. It is at this time where his attending
physician ordered another Laboratory request for CBC and PC to check if
Patient X’s platelet count is below the normal range of 150,000 to 350,000/L,
which is referred to as thrombocytopenia. The laboratory request was done in
anticipation of a possible bleeding episode where blood transfusion or platelet
transfusion will be administered. Frank bleeding is a worst case scenario for
a patient suffering from DHF. Laboratory test results is not indicative of
platelet count below 20,000 /L which would place the patient a candidate for
hemorrhagic bleeding.
After the significant drop of the client’s temperature, Patient X temperature
were elevated again for eight hours, a normal phenomenon for a DHF patient
before entering into the convalescent stage. His fifth day up to his seventh
day stay in the pediatric ward was a period of recuperation. Patient X’s
Attending Physician noted the appearance of Herman’s rash on his sixth day,
which is an indication that the patient is fully recovering since a rash after
the period of toxic stage is common to a patient suffering from DHF.
DENGUE HEMORRHAGIC FEVER 2

The patient was discharged on the seventh day with a resolving Dengue
Hemorrhagic Fever as his final diagnosis.
Dengue is an important differential diagnosis of fever in children and adults
presenting to first-level health facilities in tropical Asia and Latin America.
Dengue is not included in the generic Integrated Management of Childhood
Illnesses (IMCI) algorithm, but due to its importance, it was incorporated in
several Asian and Latin American IMCI adaptations. Most of these
adaptations have not been tested for their performance.
Prior to and in parallel with IMCI, there have been guidelines develop, on the
management of dengue. The “Guidelines for Treatment of Dengue
Fever/Dengue Hemorrhagic Fever in Small Hospitals” develop by the WHO
Regional Office is widely used. There has been no previous summary of
existing dengue guidelines to explore their usefulness in the context of IMCI
and to identify questions for research.
Dengue cases have become a normal occurrence at this time of the year and
it is always safe to remind people continuously about the danger of this
disease. This case study aims to identify and determine the general health
problems and needs of the patient with an admitting diagnosis of dengue
hemorrhagic fever. This presentation also intends to help patient promote
health and medical understanding of such condition through the application
of nursing skills. Moreover, paper is also intended to provide a better
understanding of the disease process based on the patient’s health history
and as a reference for future nursing students.
DENGUE HEMORRHAGIC FEVER 3

II. OBJECTIVES
General objective
This case study aims to identify and determine the general health problems
and needs of the patient with an admitting diagnosis of dengue hemorrhagic
fever. This presentation also intends to help patient promote health and
medical understanding of such condition through the application of nursing
skills. This paper is also intended to provide a better understanding of the
disease process based on the patient’s health history and as a reference for
future nursing students.
Specific Objectives
• To raise the level of awareness of patient and family on health
problems that they may encounter
• To facilitate the patient and family in taking necessary actions to
solve and prevent the identified problems on her own
• To trace the disease process as well as possible etiologies.
• To render nursing care and information to patient through the
application of the nursing skills.
• To create a nursing care plan for individualized care of the
patient.
DENGUE HEMORRHAGIC FEVER

III. ANATOMY AND PHYSIOLOGY
HEMATOLOGIC SYSTEM
The hematologic system consists of the blood and the sites where blood is
produced, including the bone marrow and the reticuloendothelial system
(RES). Blood is a specialized organ that differs from other organs in that it
exists in a fluid state. Blood iscomposed of plasma and various types of cells.
Plasma is the fluid portion of blood; it contains various proteins, such as
albumin, globulin, fibrinogen, and other factors necessary for clotting, as well
as electrolytes, waste products, and nutrients. About 55% of blood volume is
plasma.
BLOOD
The cellular component of blood
consists of three primary cell types :
RBCs (red blood cells or
erythrocytes), WBCs (white blood
cells or leukocytes), and platelets
(thrombocytes). These cellular
components of blood normally make
up 40% to 45% of the blood volume.
Because most blood cells have a
short life span, the need for the
body to replenish its supply of cells
is continuous; this process is termed
hematopoiesis. The primary site for
hematopoiesis is the bone marrow.
During embryonic development and
in other conditions, the liver and spleen may also be involved. Under normal
conditions, the adult bone marrow produces about 175 billion RBCs, 70 billion

neutrophils (mature form of a WBC), and 175 billion platelets each day.
When the body needs more blood cells, as in infection (when WBCs are
needed to fight the invading pathogen) or in bleeding (when more RBCs are
required), the marrow increases its production of the cells required. Thus,
under normal conditions, the marrow responds to increased demand and
releases adequate numbers of cells into the circulation.
The volume of blood in humans is approximately 7% to 10% of the normal
body weight and amounts to 5 to 6 L. Circulating through the vascular
system and serving as a link between body organs, the blood carries oxygen
absorbed from the lungs and nutrients absorbed from the gastrointestinal
tract to the body cells for cellular metabolism. Blood also carries waste
products produced by cellular metabolism to the lungs, skin, liver, and
kidneys, where they are transformed and eliminated from the body. Blood
also carries hormones, antibodies, and other substances to their sites of
action or use.
Blood is made up of plasma (fluid component) and formed elements (cellular
component). Plasma consists of about 90% water and 10% solutes
(electrolytes, albumin, globulins, and clotting factors). The formed elements
include erythrocytes (red blood cells
[RBCs]), leukocytes (white blood
cells [WBCs]), and platelets (PLTs).
To function, blood must remain in its
normally fluid state. Because blood
is fluid, the danger always exists
that trauma can lead to loss of blood
from the vascular system. To
prevent this, an intricate clotting
mechanism is activated when
necessary to seal any leak in the
blood vessels. Excessive clotting is
equally dangerous, because it can obstruct blood flow to vital tissues. To

prevent this, the body has a fibrinolytic mechanism that eventually dissolves
clots (thrombi) formed within blood vessels. The balance between these two
systems, clot (thrombus) formation and clot (thrombus) dissolution or
fibrinolysis, is called hemostasis.
BONE MARROW
The bone marrow is the site of hematopoiesis, or blood cell formation. In a
child all skeletal bones are involved, but as the child ages marrow activity
decreases. By adulthood, marrow activity is usually limited to the pelvis, ribs,
vertebrae, and sternum. Marrow is one of the largest organs of the body,
making up 4% to 5% of total body weight. It consists of islands of cellular
components (red marrow) separated by fat (yellow marrow). As the adult
ages, the proportion of active marrow is gradually replaced by fat; however,
in the healthy person, the fat can again be replaced by active marrow when
more blood cell production is required. In
adults with disease that causes marrow destruction, fibrosis, or scarring, the
liver and spleen can also resume production of blood cells by a process
known as extramedullary hematopoiesis. The marrow is highly vascular.
Within it are primitive cells called stem cells. The stem cells have the ability
to self-replicate, thereby ensuring a continuous supply of stem cells
throughout the life cycle. When stimulated to do so, stem cells can begin a
process of differentiation into either myeloid or lymphoid stem cells. These
stem cells are committed to produce specific types of blood cells. Lymphoid
stem cells produce either T or B lymphocytes.Myeloid stem cells differentiate
into three broad cell types: RBCs,WBCs, and platelets. Thus, with the
exception of lymphocytes, all blood cells are derived from the myeloid stem
cell. A defect in the myeloid stem cell can cause problems not only with WBC
production but also with RBC and platelet production. The entire process of
hematopoiesis is highly complex.

PLATELETS (THROMBOCYTES)
Platelets, or thrombocytes, are not actually cells. Rather, they are granular
fragments of giant cells in the bone marrow called megakaryocytes. Platelet
production in the marrow is regulated in part by the hormone
thrombopoietin, which stimulates the production and differentiation of
megakaryocytes from the myeloid stem cell. Platelets play an essential role
in the control of bleeding. They circulate freely in the blood in an inactive
state, where they nurture the endothelium of the blood vessels, maintaining
the integrity of the vessel. When vascular injury does occur, platelets collect
at the site and are activated. They adhere to the site of injury and to each
other, forming a platelet plug that temporarily stops bleeding. Substances
released from platelet granules activate coagulation factors in the blood
plasma and initiate the formation of a stable clot composed of fibrin, a
filamentous protein. Platelets have a normal life span of 7 to 10 days.
PLASMA AND PLASMA PROTEINS
After cellular elements are removed from blood, the remaining liquid portion
is called plasma. More than 90% of plasma is water. The remainder consists
primarily of plasma proteins, clotting factors (particularly fibrinogen), and
small amounts of other substances such as nutrients, enzymes, waste
products, and gases. If plasma is allowed to clot, the remaining fluid is called
serum. Serum has essentially the same composition as plasma, except that
fibrinogen and several clotting factors have been removed in the clotting
process. Plasma proteins consist primarily of albumin and globulins. The
globulins can be separated into three main fractions—alpha, beta, and
gamma—each of which consists of distinct proteins that have different
functions. Important proteins in the alpha and beta fractions are the
transport globulins and the clotting factors that are made in the liver. The
transport globulins carry various substances in bound form around the
circulation. For example, thyroid-binding globulin carries thyroxin, and
transferrin carries iron. The clotting factors, including fibrinogen, remain in

an inactive form in the blood plasma until activated by the clotting cascade.
The gamma globulin fraction refers to the immunoglobulins, or antibodies.
These proteins are produced by the well-differentiated lymphocytes and
plasma cells. The actual fractionation of the globulins can be seen on a
specific laboratory test (serum protein electrophoresis). Albumin is
particularly important for the maintenance of fluid balance within the
vascular system. Capillary walls are impermeable to albumin, so its presence
in the plasma creates an osmotic force that keeps fluid within the vascular
space. Albumin, which is produced by the liver, has the capacity to bind to
several substances that are transported in plasma (eg, certain medications,
bilirubin, some hormones). People with poor hepatic function may have low
concentrations of albumin, with a resultant decrease in osmotic pressure and
the development of edema.

IV. DENGUE and DENGUE HEMORRHAGIC FEVER
Overview
Dengue infection is one of the most common mosquito borne viral diseases of
public health significance. It has been identified as a clinical entity since
1780. Clinical descriptions of the Australian outbreak in 1897 reported that
30 children died. The clinical manifestations of dengue infection range from
asymptomatic infection to undifferentiated fever, an influenza-like symptom
known as dengue fever, and a severe, sometimes fatal disease characterized
by hemorrhage and shock known as dengue hemorrhagic fever (DHF). The
first and second epidemics of DHF occurred in Manila in 1954 and 1956,
followed by the third in Bangkok in 1958. Since then, DHF has spread
throughout tropical Asian countries and has expanded globally.
Dengue viruses, single stranded RNA viruses of the family Flaviviridae, are
the most common cause of arboviral disease in the world. They are found
virtually throughout the tropics and cause an estimated 50-100 million
illnesses annually, including 250,000 - 500,000 cases of dengue hemorrhagic
fever a severe manifestation of dengue and 24,000 deaths. More than two
fifths of the world's population (2.5billion) lives in areas potentially at risk for
dengue. Because travelers to endemic areas are also at risk, healthcare
providers should have an understanding of the spectrum of infection, how to
diagnose it, and what the appropriate treatment is.
Dengue infection is caused by any of four dengue virus serotypes. The clinical
manifestations range from asymptomatic infection to undifferentiated fever,
dengue fever and dengue hemorrhagic fever (DHF). DHF is characterized by
sustained high fever for 2–7 days; bleeding diathesis such as positive
tourniquet test, petechiae, epistaxis and hematemesis; thrombocytopenia
with platelet counts less than 100 x 109
L and plasma leakage due to
increased vascular permeability evidenced by hemoconcentration, pleural
effusion and ascites. Bleeding diathesis is caused by vasculopathy,
thrombocytopenia, platelet dysfunction and coagulopathy. The three stages

of clinical presentations are classified as febrile, toxic and convalescent. The
toxic stage, which lasts 24–48 hours, is the most critical period, with rapid
plasma leakage leading to circulatory disturbance. The severity of DHF varies
from mild (World Health Organization grades I and II), with minimal and
transient change in vital signs, to severe (World Health Organization grades
III and IV), with threatened shock (e.g. blood pressure 100/90 mmHg) or
profound shock. There is no specific treatment for DHF. Intensive supportive
care is the most important aspect of management. Early recognition of the
disease and careful monitoring for circulatory disturbance are essential.
Optimal fluid therapy to maintain the functions of the vital organs during the
critical period and effective control of bleeding episodes will lead to favorable
outcomes. Administration of recombinant activated factor VII is suggested
whenever massive bleeding does not respond to blood component therapy.
SOCIO-DEMOGRAPHIC PROFILE
Dengue is a mosquito-borne infection which in recent years has become a
major international public health concern. Dengue is found in tropical and
sub-tropical regions around the world, predominantly in urban and semi-
urban areas.
Dengue hemorrhagic 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.
An outbreak of dengue fever occurred in Cebu City from August 1987 to
January 1988. A total of 752 cases were hospitalized; 269 records were
reviewed, 20 patients were interviewed, and 18 blood samples were
collected. The majority of the cases were from urban areas. Seventy percent
of the cases were aged 10 years and younger. Fifty-three percent were
classical dengue fever; 22% Grade I; 21% Grade II; and 7% Grade III.
There were three deaths; the case fatality ratio was 0.4%. Three of the 18
blood samples grew dengue virus serotype 1.

There are four distinct, but closely related, viruses that cause dengue.
Recovery from infection by one provides lifelong immunity against that
serotype but confers only partial and transient protection against subsequent
infection by the other three. There is good evidence that sequential infection
increases the risk of more serious disease resulting in DHF.
Prevalence
The global prevalence of dengue has grown dramatically in recent decades.
The disease is now endemic in more than 100 countries in Africa, the
Americas, the Eastern Mediterranean, South-east Asia and the Western
Pacific. South-east Asia and the Western Pacific are most seriously affected.
Before 1970 only nine countries had experienced DHF epidemics, a number
that had increased more than four-fold by 1995.
Some 2500 million people -- two fifths of the world's population -- are now at
risk from dengue. WHO currently estimates there may be 50 million cases of
dengue infection worldwide every year.
In 2001 alone, there were more than 609 000 reported cases of dengue in
the Americas, of which 15 000 cases were DHF. This is greater than double
the number of dengue cases which were recorded in the same region in
1995.
Not only is the number of cases increasing as the disease is spreading to new
areas, but explosive outbreaks are occurring. In 2001, Brazil reported over
390 000 cases including more than 670 cases of DHF.
Some other statistics:
During epidemics of dengue, attack rates among susceptible are often 40 --
50%, but may reach 80 -- 90%.
An estimated 500 000 cases of DHF require hospitalization each year, of
whom a very large proportion are children. At least 2.5% of cases die,
although case fatality could be twice as high.
Without proper treatment, DHF case fatality rates can exceed 20%. With
modern intensive supportive therapy, such rates can be reduced to less than
1%.

The spread of dengue is attributed to expanding geographic distribution of
the four dengue viruses and of their mosquito vectors, the most important of
which is the predominantly urban species Aedes aegypti. A rapid rise in
urban populations is bringing ever greater numbers of people into contact
with this vector, especially in areas that are favorable for mosquito breeding,
e.g. where household water storage is common and where solid waste
disposal services are inadequate.
Clinical Presentation
Dengue fever is a severe, flu-like illness that affects infants, young children
and adults, but seldom causes death.
The clinical features of dengue fever vary according to the age of the patient.
Infants and young children may have a non-specific febrile illness with rash.
Older children and adults may have either a mild febrile syndrome or the
classical incapacitating disease with abrupt onset and high fever, severe
headache, pain behind the eyes, muscle and joint pains, and rash.
The three stages of clinical presentation are named febrile, toxic
(hemorrhagic stage) and convalescent. The patients initially develop an
abrupt onset of high fever (39–40 °C) with malaise, headache, nausea,
vomiting, myalgia and, sometimes, abdominal pain. During the acute febrile
stage, which lasts 2–7 daysb (from DOH it is within the first 4 days),
hemorrhagic manifestation is invariably present but usually mild. Petechial
hemorrhage on the skin is commonly found. Also, a positive tourniquet test is
frequently observed. Bleeding at the nose, gastrointestinal tract (manifested
by abdominal pain) and gums is relatively less common compared with
petechiae, but may be severe. Flushing which may be accompanied by
vomiting, conjuctival infection and epistaxis may be observed at a later
period. Recently, menorrhagia has been more prevalent because of the
increasing number of affected adolescents. However, hematuria is extremely
rare. Hepatomegaly is commonly found, and the liver is usually soft and
tender. Thrombocytopenia and rising hematocrit due to plasma leakage are

usually detectable before the onset of the subsequent toxic stage. An abrupt
fall to normal or subnormal levels of temperature, varying degrees of
circulatory disturbance will develop, known as the toxic stage, lasts 24–48
hours. Ultimately, the majority of patients have rapid uneventful recovery
without sequelae in the convalescent stage.
Dengue hemorrhagic fever is a potentially deadly complication that is
characterized by high fever, hemorrhagic phenomena--often with
enlargement of the liver--and in severe cases, circulatory failure. The illness
commonly begins with a sudden rise in temperature accompanied by facial
flush and other non-specific constitutional symptoms of dengue fever. The
fever usually continues for two to seven days and can be as high as 40-41°C,
possibly with febrile convulsions and hemorrhagic phenomena.
In moderate DHF cases, all signs and symptoms abate after the fever
subsides. In severe cases, the patient's condition may suddenly deteriorate
after a few days of fever; the temperature drops, followed by signs of
circulatory failure, and the patient may rapidly go into a critical state of
shock and die within 12-24 hours, or quickly recover following appropriate
volume replacement therapy.
Diagnostic Criteria
The clinical diagnosis of DHF is based on four major characteristic
manifestations:
(i) sustained high fever lasting 2–7 days;
(ii) hemorrhagic tendency such as a positive tourniquet test, petechiae or
epistaxis;
(iii) thrombocytopenia (platelet count less than 100 x 109
/L); and
(iv) evidence of plasma leakage manifested by hemoconcentration (an
increase in hematocrit greater than 20% above average for age, sex
and population), pleural effusion and ascites.
Close observation, serial hematocrit and daily platelet count monitoring are
suggested in order to accomplish the clinical diagnostic criteria. Pleural

effusion can be demonstrated by a chest X-ray in right lateral decubitus view
at 12–24 hours after defervescence. These applications may be problematic
in a busy pediatric practice in a dengue-endemic area. A study in Vietnam
suggested to use fever and hemoconcentration together with either bleeding
or thrombocytopenia as clinical criteria of DHF. However, some patients with
bleeding or anemia will not have a rising hematocrit. Therefore, the minimal
criteria should include fever and evidence of plasma leakage together with
either bleeding or thrombocytopenia. Further evaluation in a large
prospective series from other dengue-endemic regions is warranted. The
severity of DHF is categorized into four grades: grade I, without overt
bleeding but positive for tourniquet test; grade II, with clinical bleeding
diathesis such as petechiae, epistaxis and hematemesis; grade III,
circulatory failure manifested by a rapid and weak pulse with narrowing pulse
pressure ( less than 20 mmHg) or hypotension, with the presence of cold
clammy skin and restlessness; and grade IV, profound shock in which pulse
and blood pressure are not detectable.

V. PATHOPYSIOLOGY
Etiologic agent
Dengue viruses’ type 1, 2, 3, & 4
Alternative Names
Hemorrhagic dengue; Dengue shock syndrome; Philippine hemorrhagic
fever; Thai hemorrhagic fever; Singapore hemorrhagic fever
Definition/Transmission
Dengue hemorrhagic fever is a severe, potentially deadly infection bite by
certain mosquitoes (Aedes aegypti ). Day biting female mosquito that breeds
in the household or standing clean water.
Dengue viruses are transmitted to humans through the bites of infective
female Aedes mosquitoes. Mosquitoes generally acquire the virus while
feeding on the blood of an infected person. After virus incubation for 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, but the role of this in sustaining
transmission of virus to humans has not yet been delineated.
Humans are the main amplifying host of the virus, although studies have
shown that in some parts of the world monkeys may become infected and
perhaps serve as a source of virus for uninfected mosquitoes. The virus
circulates in the blood of infected humans for two to seven days, at
approximately the same time as they have fever; Aedes mosquitoes may
acquire the virus when they feed on an individual during this period.
Incubation Period
Uncertain, Probably 6 days to one week.

Period of Communicability
Unknown. Presumed to be on the first week of illness when virus is still
present in the blood.
Susceptibility, Resistance and Occurence
All persons are susceptible. Both sexes are equally affected. Age groups
predominantly affected are the preschool and school age. Adults and infants
are not exempted. Peak age affected 5-9 years of age.
Occurrence is sporadic throughout the year. Epidemic usually occur during
the rainy season as June – November. Peak months are September and
October.
Susceptibility is universal. Acquired immunity may be temporary but usually
permanent.
Causes
Four different dengue viruses have been shown to cause dengue hemorrhagic
fever. This condition occurs when a person catches a different dengue virus
after being infected by another type sometime before. Prior immunity to a
different dengue virus type plays an important role in this severe disease.
Worldwide, more than 100 million cases of dengue fever occur every year. A
small number of these develop into dengue hemorrhagic fever. Most
infections in the United States are brought in from other countries. It is
possible for a traveler who has returned to the United States to pass the
infection to someone who has not traveled.
Risk factors for dengue hemorrhagic fever include having antibodies to
dengue virus from prior infection and being younger than 12, female, or
Caucasian.
Pathogenesis
The pathogenesis of DHF is poorly understood. DHF caused by primary or
secondary dengue infection is due to the occurrence of abnormal immune
response involving production of cytokines or chemokines, activation of T-
lymphocytes and disturbance of the hemostatic system. upon the second

infection with a heterotypic dengue virus, the subneutralizing concentration
of the cross-reacting antibody from the previous infection may opsonize the
virus and enhance its uptake and replication in the macrophage or
mononuclear cells. Secondary infection with a heterotypic dengue virus is
associated with increased risk of developing DHF in individuals who have
recovered from a primary dengue virus with a first serotype. The level of T-
cell activation in a secondary dengue infection is also enhanced, occurring as
a phenomenon known as original antigenic sin, and is undergoing
programmed cell death. Many denguespecific T-cells are of low affinity for
the infected virus and show higher affinity for other, probably previously
encountered serotypes. Profound T-cell activation and death during acute
dengue infection may suppress or delay viral elimination, leading to the
higher viral loads and increased immunopathology found in patients with DHF
Symptoms
Early symptoms of dengue hemorrhagic fever are similar to those of dengue
fever, but after several days the patient becomes irritable, restless, and
sweaty. These symptoms are followed by a shock-like state.
Bleeding may appear as pinpoint spots of blood on the skin (petechiae) and
larger patches of blood under the skin (ecchymoses). Bleeding may occur
from minor injuries. Shock may cause death. If the patient survives, recovery
begins after a one-day crisis period.
Early symptoms include the following:
• Fever
• Headache
• Muscle aches
• Joint aches
• Malaise
• Decreased appetite
• Vomiting
Acute phase symptoms include the following:
• Shock-like state
• Sweaty (diaphoretic)
• Cold, clammy extremities

• Restlessness followed by:
o Worsening of earlier symptoms
o Petechiae
o Ecchymosis
o Generalized rash
The severity of DHF is categorized into four grades: grade I, without overt
bleeding but positive for tourniquet test; grade II, with clinical bleeding
diathesis such as petechiae, epistaxis and hematemesis; grade III,
circulatory failure manifested by a rapid and weak pulse with narrowing pulse
pressure ( less than 20 mmHg) or hypotension, with the presence of cold
clammy skin and restlessness; and grade IV, profound shock in which pulse
and blood pressure are not detectable.
Evidence of plasma leakage
The plasma leakage is due to the increased vascular permeability induced by
several mediators such as C3a, C5a during the acute febrile stage and
prominent during the toxic stage. The evidence of plasma leakage includes
Category I Category II Category III Category IV
History or
presence of
fever 2-7
days duration,
with a (+)
tourniquet
test or
presence of
skin flushing
or petechial
rash
Category I plus
Presence of one or more
Danger Signs (especially
defervescence)
Restlessness
Changes in sensorium
Cold, clammy skin
Sudden onset of
abdominal pain
Difficulty of breathing
Circumoral cyanosis
Seizures
Spontaneous bleeding
(gum bleeding,
epistaxis, rashes,
petechiae)
Category II plus
Circulatory failure
Cold clammy skin
Weak thready
pulse
Narrow pulse
pressure ( less
than 20mm/Hg)
Hypotension
Restlessness
Category III
plus profound
shock with
undetectable
pulse and
blood
pressure

hemoconcentration, hypoproteinemia/hypoalbuminemia, pleural effusion,
ascites, threatened shock and profound shock. The rising hematocrit may not
be evidenced because of either severe bleeding or early intravenous fluid
replacement.
Bleeding tendency
The bleeding diathesis is caused by vasculopathy, thrombocytopenia, platelet
dysfunction and coagulopathy.
Vasculopathy
A positive tourniquet test indicating the increased capillary fragility is found
in the early febrile stage. It may be a direct effect of dengue virus as it
appears in the first few days of illness during the viremic phase.
Thrombocytopenia and platelet dysfunction.
Patients with DHF usually have platelet counts less than 100 x 109
/L.
Thrombocytopenia is most prominent during the toxic stage. The
mechanisms of thrombocytopenia include decreased platelet production and
increased peripheral destruction. The increased peripheral destruction is
markedly prominent during 2 days before defervescence. The bone marrow
then revealed hypercellularity with an increase in the megakaryocyte,
erythroblast and myeloid precursors. Hemophagocytosis of young and
mature erythroid and myeloid cells, lymphocytes and platelets was observed
Subsequently, the number of platelets is rapidly increased in the
convalescent stage and reaches the normal level within 7–10 days after the
defervescence.
Platelet dysfunction as evidenced by the absence of adenosine diphosphate
(ADP) release was initially demonstrated in patients with DHF during the
convalescent stage. The subsequent study during the febrile and early
convalescent stages by Srichaikul et al. in 1989 also demonstrated the
impaired platelet aggregation response to ADP that returned to a normal
response 2–3 weeks later. An increase in plasma - thromboglobulin and
platelet factor 4, indicating increased platelet secretory activity, was

observed. The platelet dysfunction might be the result of exhaustion from
platelet activation triggered by immune complexes containing dengue
antigen.
Coagulopathy
During the acute febrile stage, mild prolongation of the prothrombin time and
partial thromboplastin time, as well as reduced fibrinogen levels, have been
demonstrated in several studies. Variable reductions in the activities of
several coagulation factors, including prothrombin, factors V, VII, VIII, IX
and X, antithrombin and antiplasmin, have been demonstrated. Fibrin
degradation product or D-dimer is slightly elevated. Low levels of
anticoagulant proteins C and S and antithrombin III were found to be
associated with increasing severity of shock, presumably due to plasma
leakage. Elevated levels of tissue factor, thrombomodulin and plasminogen
activator inhibitor-1 reflect endothelial, platelet and/or monocyte activation
and may be a secondary response to direct activation of fibrinolysis by the
dengue virus. The coagulation abnormality is well compensated for in the
majority of patients without circulatory collapse. Most of the patients have
serum aspartate transaminase (AST) and alanine transaminase (ALT) levels
three and twofold higher than normal, respectively. There is focal necrosis of
hepatic cells, swelling appearance of Councilman bodies and hyaline necrosis
of Kupffer cells. Proliferation of mononuclear leucocytes and less frequently
polymorphonuclear leucocytes occurs in the sinusoids and occasionally in the
portal areas.
Possible Complications:
• Shock
• Encephalopathy
• Residual brain
damage
• Seizures
• Liver damage

Diagnostic Procedure
Physical examination may reveal the following:
• Low blood pressure
• A weak, rapid pulse
• Rash
• Red eyes
• Red throat
• Swollen glands
• Enlarged liver
(hepatomegaly)
Tests may include the following
• Hematocrit
• Platelet count
• Electrolytes
• Coagulation studies
• Liver enzymes
• Tourniquet test (capillary fragility test or Rumpel Leads test) a
presumptive test which is positive in the presence of more than 20
petechiae within an inch square, after 5 minutes of test.
 Inflate BP cuff on upper arm to a point midway between the systolic
and diastolic pressure of 5 min

 Release cuff and make an imaginary 1square inch just below the
cuff, at the antecubital fossa
 Count the number of petechiae inside the box
• X-ray of the chest (may demonstrate pleural effusion)
• Serologic studies (demonstrate antibodies to Dengue viruses)
• Serum studies from samples taken during acute illness and
convalescence (increase in titer to Dengue antigen)
Get baseline platelet count and hematocrit; repeat daily if platelet
count is <100,000/uL
• Take serial platelet count and hematocrit 1-3x daily
• Monitor vital signs and urine output
• Request for blood typing, clotting time and bleeding time
• If necessary, do chest x-ray to assess pleural effusion, ECG for
myocarditis, or ABGs for metabolic acidosis
• Optional: prothrombin time, partial thromboplastin time, fibrinogen,
total protein, albumin, globulin
Medical Management
Management Protocol in DHF by Dept. of Health (strategies)
• Case diagnosis, management, referral
• Health education/Advocacy
• Rapid response mosquito control
• Research and project development
• Integrated vector control
• Surveillance
• Training
Medical Treatment
• Symptomatic and supportive relief

• Rapid replacement of Fluids (most important treatment) like oresol
and IV
o Give oresol at 75ml/KBW in 4-6hrs then maintain patient at
1-2L/day; continue giving other types of home fluids.
o Start IVF using D5LRS or D5 0.9NaCl or plain LRS:
o Give IVF at 5-7ml/KBW/hr if there is hemoconcentration or
signs of plasma leakage. Then reduce IVF rate to
3ml/KBW/hr if there is subsequent improvement. Discontinue
IVF after 24-48hrs if child remains stable. Otherwise, IVF
may be increased by 3-5ml increments up to 15ml/KBW/hr
until there is improvement and as long as patient is not in
shock or there is no significant blood loss.
o Give IVF at 10-20ml/KBW IV bolus in <20minutes if patient
is in shock; Repeat dose if there is no immediate
improvement. Give plasma, plasma substitutes or 5%
albumin at 10-20ml/KBW as rapid bolus if hematocrit rises
and shock is still present. Give oxygen. Once improvement
occurs adjust IVF same as above
o Give fresh whole blood at 1-ml/KBW if there is significant
blood loss or if hematocrit continues to fall despite fluid
resuscitation. If there is frank, uncontrolled bleeding.
o Give platelets when platelet count is below 150,000/uL or if
there is significant blood loss and platelet count is below
150,000/uL, or there is continuous bleeding and hematocrit
remains normal.
o Use fresh frozen plasma or cryoprecipitate in DIC. Correct
metabolic acidosis
o Give oresol to replace fluid as in moderate dehydration at
75ml/kg in 4-6 hours or up to 2-3L in adults. Continue ORS
intake until patients condition improves.
• Paracetamol (NO ASPIRIN), for headache give analgesic

• Fresh whole blood transfusion is ordered if thrombocytopenia and
platelet declines
• For nose bleeding, flex the neck to prevent aspiration. Keep an
elevated position of trunk and promote vasoconstriction in nasal
mucosa membrane through an ice bag over the forehead
• For melena, ice bag over the abdomen.
• Avoid unnecessary movement
• Assist in the management of shock. Dorsal recumbent to
trendelenburg position. Dorsal recumbent position facilitates
circulation.
• For shock, provide warmth through lightweight covers, (overheating
causes vasodilation which aggravates bleeding)
• Monitor vital signs, especially temperature because the critical period
for early signs of shock is the transition from febrile to afebrile phase
• Diet: Low fat, low fiber, non irritating, non carbonated, non acidic
food. Noodle soup may be given. No dark colored foods, which can
be mistaken as melena for a dark colored stool.
• The following have no role in treatment/or have not been
assessed adequately: Vit. C, steroids, IVIg
Outlook (Prognosis)
With early and aggressive care, most patients recover from dengue
hemorrhagic fever. However, half of untreated patients who go into shock do
not survive

VI. COMPREHENSIVE HEALTH HISTORY
Patient X is 2 years and 9 months old a male toddler born and raised from
South Cotabato
Informant: Patient’s mother
Reliability: 100%
Patient: Patient X
Birthday: November 10, 2005
Nationality: Filipino
Address: 271B, 61D, PA. South Cotabato
Type of Admission: Direct from ER
Attending Physician: Dr. X
Final Diagnosis: Dengue Hemorrhagic Fever II
Ward: Pediatric Ward
Hx: This is a case of a 3 year-old male with DHF II
Chief complaint: Fever
HPI:
10 hours PTA - (+) high grade fever, vomiting for several hours

Patient History
Patient X is a toddler, admitted into the hospital around 5:00 am carried by
his mother.
He is born healthy, under normal spontaneous vaginal delivery without any
body-marks or observable congenital birth defects. He has completed his
immunization program for the following vaccines: BCG, DPT, OPV, MEASLES
and HEPA-B.
Patient X being the youngest of three 3 siblings, stays with her mother most
of time at home. This is his first time to contact a serious illness since his
birth. Most of the time he frequently catch common colds and slight to
moderate fever but not of a high grade fever. The night prior to his
admission to the hospital, patient X is feverish and it worsens in the wee
hours of the morning. Patient is irritable, crying and has vomited for about
three times.

VII. PHYSICAL ASSESSMENT
CATEGORY FINDINGS
General Appearance The patient looks weak and with eyebags.
Vital Signs Temperature: 40.5
Respiration: 30 cpm
Pulse Rate: 110
Blood Pressure: 90/40
Skin Upon inspection, the patient was noted to have
flushed skin color
Hair The patient’s natural hair color is black. Soft and
shiny.
Head/skull Upon inspection the skull is symmetrically aligned.
No signs of lesions.
Eyes Eyes and eyebrows are symmetrically aligned with
equal distribution of hair on both eyebrows.
PERRLA
Ears The color of both ears is the same with the facial
skin and is symmetrically aligned. No ear discharge
is noted.
Nose The external nose is symmetric and straight same
color as with the facial skin. There is no nasal
flaring. No obstruction in both nasal cavities
Lips Appears to be a little bit dry but not bluish or
cyanotic. No lesions, cracks or warts are present
Neck The patient can move his head freely, no nodules
palpated in the cervical area
Thorax/Lung Normal respiration, symmetrical chest expansion,
clear breath sounds, negative retraction.
Heart/Cardiovascular Normal cardiac rate, symmetrical peripheral pulse
noted.
Abdomen Normal bowel sound. Soft non tender abdomen
Muscoloskeletal Motor @ 4/5 upper and lower extremities
Both appear to be symmetric
Mental Status Conscious and oriented

Head and Neck:
(-) Decreased hearing
(-) Ringing in ears
(-) Frequent ear infections
(-) Dizzy spells
(-) Failing vision
(-) Double vision
(-) Blurred vision
(-) Eye pain
(-) Repeated eye infections
(-) Recurrent nose bleeds
(-) Dental disease
(-) Sinus trouble
(-) Frequent sore throats
(-) Neck swelling
(-) Hay fever
Respiratory
(-) Hoarseness
(-) Persistent cough
(-) Blood in spit
(-) Shortness of breath
Cardiovascular
(-) Chest pain traveling down left arm
(-) Palpitations
(-) Irregular heart beat
(-) Swollen ankles
(-) Fainting spells
(-) Pain in legs when walking
Genitourinary
(-) Painful urination
(-) Blood in urine
(-) Frequent urination
(-) Night time urinary frequency
(-) Loss of control of urine
(-) Decrease in force of urine stream
(-) Sexual dysfunction

Endocrine
(-) Chronic fatigue
(-) Weight loss – recent
(-) Bruise easily
(-) Cold extremities
(-) Tremors (shaking of hands)
(-) Convulsions
(+) Muscle weakness
Neurological
(-) Numbness
(-) Tingling sensations
(+) Headaches
(-) Nervousness
(-) Memory Loss
(-) Moodiness
(-) Difficulty falling asleep
(-) Difficulty staying awake
(+) Increased irritability
Musculoskeletal
(-) Neck pain
(-) Joint pain
(-) Low back pain
(-) Foot pain
(-) Stiff joints
Skin
(-) Petechiae rashes
(-) Hives
Past Medical History:
(-) previous hospitalization / OR / accidents
(-) asthma / allergy

HEMATOLOGY RESULT
Day 1
Hemoglobin-13.6 M:(13.0-18.0 Cms%) RBC 4.7 M: (4.5-6.5x10 L)
F:(12.0-18.0 Cms%) F: (3.8-5.8x10 L)
C:(11.7-13-0 Cms%) C: (4.0-5.2x10 L)
Hematocrit- 0.41 M:(0.40-0.54 Vol%) WBC---4.7---(4.5-10X10 L)
F:(0.37-0.47 Vol%)
C:(0.32-0.42 Vol%)
Differential Count:
Segmenters-----0.80 (0.50-0.70) Blood Type O+
Lymphocytes---0.20 (0.20-0.40) Bleeding Time----(1-4mins)
Eosinophils------------(0.01-0.05) Clotting Time-----(2-5mins)
Basophils---------------( -0.01 E.S.R M:(0.10mm/hr)
Monocytes--------------( -0.03) F: (0.20mm/hr)
Platelet Count—138 -(150-350 L)
Malarial Smear:_________________________
Others:________________________________
_________________________________ ______________________
(Commanding Officer) (Medical Technologist)
_________________________________ ______________________
(Comanding Officer) (Medical Technologist)

The Complete Blood Count is a screening test, used to diagnose and manage
numerous diseases. Test results shows normal value for Lymphocytes.
Eosiniphils Basophils and Monocytes values were not included in the
laboratory result, a marked increased in WBC indicates a positive infection.
Neutrophils/Segmenters are elevated, suggestive of Bacterial infection.
Lymphocytes are responsible for immune responses. An elevation is present
in cases of viral infection, leukemia, cancer of the bone marrow, or radiation
therapy while a decreased lymphocyte level can indicate diseases that affect
the immune system. A significant decrease in lymphocyte value indicates
low immune response.
Hematocrit values are indicators of ratio of RBC in relation to blood volume.
This is best compared with Hemoglobin value since the two values are
indicative of RBC present in the blood. The oxygen-combining ability of the
blood is in direct proportion to the hemoglobin concentration, rather than the
numbers of red blood cells, because some cells contain more hemoglobin
than others. Hemoglobin also serves as an important pH buffer in the
extracellular fluid. Hemoglobin determination is used to screen for anemia, to
identify the severity of anemia, and to assist in evaluating the patient's
response to anemia therapy. While a patient with a platelet count of less than
20,000 is at high risk for spontaneous bleeding.

HEMATOLOGY RESULT
Day 4
Hemoglobin-14.3 M:(13.0-18.0 Cms%) RBC 5 M: (4.5-6.5x10 L)
F:(12.0-18.0 Cms%) F: (3.8-5.8x10 L)
C:(11.7-13-0 Cms%) C: (4.0-5.2x10 L)
Hematocrit- 0.43 M:(0.40-0.54 Vol%) WBC---8.2---(4.5-10X10 L)
F:(0.37-0.47 Vol%)
C:(0.32-0.42 Vol%)
Differential Count:
Segmenters-----0.36 (0.50-0.70) Blood Type O+
Lymphocytes---0.64 (0.20-0.40) Bleeding Time----(1-4mins)
Eosinophils------------(0.01-0.05) Clotting Time-----(2-5mins)
Basophils---------------( -0.01) E.S.R M:(0.10mm/hr)
Monocytes--------------( -0.03) F: (0.20mm/hr)
Platelet Count—190 -(150-350 L)
Malarial Smear:_________________________
Others:________________________________
_________________________________ ______________________
(Commanding Officer) (Medical Technologist)
_________________________________ ______________________
(Comanding Officer) (Medical Technologist)
A decrease in neutrophils is known as neutropenia. Although most bacterial
infections stimulate an increase in neutrophils, some bacterial infections such
as typhoid fever and brucelosis and many viral diseases, including hepatitis,
influenza, rubella, rubeola, and mumps, decrease the neutrophil count. An
overwhelming infection can also deplete the bone marrow of neutrophils and
produce neutropenia.

URINALYSIS RESULT
Day 1
Physical Appearance
Microscopic
Test Result Normal
Pus Cell 0-3 Absent
RBC 0-1 0-5
Epithelial Cells Occasional
Protein Negative Absent
Crystal
Amorphous urates Positive
Amorphous Phosphate Blank
Test Result Normal
Color Yellow Yellow
Transparency Slightly hazy Clear
Reaction PH 6.0 4.6 - 8.0
Specific Gravity 1.030 1.010 – 1.035
Sugar Negative Absent

Urinalysis can disclose evidence of diseases, even some that have not caused
significant signs and symptoms. The color of urine is normally yellow, but if it
is reddish, this is indicative of presence of blood in the urine. Urine
transparency should be clear. Urine specific gravity measures the
concentration of particles in the urine. Increased urine specific gravity may
indicate dehydration, glycosuria and heart failure. Decreased urine specific
gravity may indicate excessive fluid intake and pyelonephritis. Urine normally
contains no glucose and abnormal results may indicate excessive diabetes
mellitus, renal glycosuria and increase Intra-Cranial Pressure. Protein is
normally not found the urine, specifically albumin. The most common cause
of protein in the urine is glomerular damage from renal disease, renal
distress, cardiac failure and febrile condition. Presence of pus cells can mean
there is kidney disease or an infection of the kidney, bladder or urinary
tubes. The presence of abnormal numbers of white cells in the urine is
referred to as pyuria. Normally there is no hemoglobin or RBC in the urine.
RBC in the urine may be due to many causes including kidney damage,
tumors eroding the urinary tract, stones, UTI and bleeding disorders.
The Appearance of urine, which is slightly turbid indicates infection. This is
even supported by the presence of pus in the urine. Presence of protein
indicates a renal distress. The increased specific gravity signifies dehydration
and glycosuria, supported by presence of glucose in the urine. Any
measurement below 1.007 to 1.010 indicates hydration and any
measurement above it indicates relative dehydration. Urine having a specific
gravity over 1.035 is either contaminated, contains very high levels of
glucose, or the patient may have recently received high density radiopaque
dyes intravenously for radiographic studies or low molecular weight dextran
solutions. Amorphous urates are observed in acidic urines and amorphous
phosphates are found in alkaline urine. The amorphous urates seen in urine
specimens are of little clinical value.

FECALYSIS
Day 3
Color: Yellow
Consistency: Soft
Fecalysis result is normal, no dark colored bowel that would indicate GI bleeding.
TYPHIDOT
Day 3
Test Result:
IgG : Positive
IgM : Negative
Interpretation of typhidot test should be based on the result of IgM. A positive IgM is
indicative of typoid fever. Typhidot test can be used as a valid tool in the diagnosis of
typhoid fever among Filipinos but whenever feasible, confirmation with blood cultures is
strongly encouraged especially with the appearance of drug resistant strains in the
community. A valid conclusion can be made from a single sample based on results of
IgM titer. Typhidot offers the advantage of speed, simplicity and early diagnosis.

SUMMARY OF LABORATORY RESULTS
Laboratory Exams Day 1 Day 3 Day 4 Normal Values
Hematology Resut
Hemoglobin 13.6 14.3 13.0 - 18.0 Cms%
Hematocrit 0.41 0.43 0.40 - 0.54 Vol%
RBC 4.7 5 4.5 - 6.5x10 L
WBC 4.7 8.2 4.5 - 5.2x10 L
Segmenters 0.80 0.36 0.50 - 0.70
Lymphocytes 0.20 0.64 0.20 - 0.40
Platelet 138 190 150 - 350
Urinalysis
Physical Appearance
Colory Yellow Yellow
Transparency Slightly Hazy Clear
Reaction pH 6.0 4.6 - 8.0
Specific Gravity 1.03 1.010 - 1.035
Sugar Negative Absent
Microscopic
Pus Cell 0-3 Absent
RBC 0-1 0 - 5
Epithelial Cells Occasional
Crystal
Amorphous urates Positive
Amorphous Phosphate Blank
Fecalysis
Color Yellow
Consistency Soft
Typhidot
IgG Positive
IgM Negative

TPR SHEET
Day 1
Hours Temperature Pulse
Rate
Respiratory
Rate
Blood
Pressure
8H 40.5 110 30
12H 39.8 105 37
4H 37.5 102 35
8H 38.0 108 40
12H 38.8 108 30
4H 37.2 114 32
Day 2
Hours Temperature Pulse Rate Respiratory
Rate
Blood
Pressure
8H 37.6 102 24
12H 39.2 102 18
4H 39.3 122 24
8H 37.5 100 27
12H 37.8 106 25
4H 38.1 108 27
Day 3
Hours Temperature Pulse
Rate
Respiratory
Rate
Blood
Pressure
8H 38.3 110 28
12H 37.8 114 27
4H 38.1 116 26
8H 37.1 110 27
12H 37.8 112 28
4H 38.8 116 29 90/40

Day 4
Rate
Blood
Pressure
8H 38.2 118 40
12H 38.2 118 35
4H 36.8 118 37
8H 39.4 126 40
12H 38.3 114 34
4H 37.2 94 37
Day 5
Rate
Blood
Pressure
8H 37.3 96 23
12H 37.2 94 23
4H 36.6 82 22
8H 36.4 78 22
12H 36.0 70 26
4H 36.0 70 26
Day 6
Hours Temperature Pulse Rate Blood
Pressure
8H 37.3 94 28 90/50
12H 36.3 112 28 90/60
4H 36.4 100 28
8H 36.5 100 28 90/60
12H 36.0 102 26
4H 36.0 98 25 90/60

IV FLOW SHEET
Date
/Time
Started
Bot.
No.
Solution/
AMT/MEDS
ADDED/ RATE
IV SITEAMT
INFUS
ED
Date
/Time
Started
AMOUNT
ENDORSE
D
SIG
9/26
0745H
1 D5 0.3% NaCl
500cc x
50mggts/min
Right
Hand
500cc 2330H 30cc
9/26
2330H
2 D5IMB 500cc X
50mggts/min
Right
Hand
500cc 0945H 280cc
9/26
1000H
3 D5IMB 500cc X
50mggts/min
Right
Hand
500cc 9/27/06
1040H
180cc
9/28
1040H
4 D5IMB 500cc X
50mggts/min
Right
Hand
500cc 9/28/06
2300H
20cc
9/28
2300H
5 D5IMB 500cc X
50mggts/min
Right
Hand
500cc 9/29/06
2300H
220cc
9/29
2300H
6 D5IMB 500cc X
50mggts/min
Left
Hand
500cc 9/30/06
0815H
80cc
9/30
0815H
7 D5IMB 500cc X
50mggts/min
Left
Hand
500cc 10/01/06
0115H
110cc
10/01
0115H
8 D5IMB 500cc X
50mggts/min
Left
Hand
500cc 10/01/06
0135H
10/01
1605H
9 D5IMB 500cc X
50mggts/min
Left
Hand
500cc 10/01/06
0345H
10/01
1345H
10 D5IMB 500cc X
50mggts/min
Left
Hand
500cc

IX. MEDICAL AND SURGICAL NURSING
Admission/Emergency Notes: Day 1
Assessment
Patient (+)Tonsillopharyngitis
Clear Breath Sounds
VS:
RR = 30 PR = 110
T = 40.5 BP = 90/40
Physicians Order
DIAGNOSTICS
• CBC
• QPC - done
• Urinalysis - done
• Stool Examination
THERAPEAUTICS
• Admit to Pediaward
• TPR every shift
• DAT (Diet as Tolerated)
• Monitor Vital Signs
• Ampicillin 130 mg IV q8h ANST
• Paracetamol 125mg/5ml  5ml q4h RTC
• Paracetamol 300 mg/amp  ½ ampule IV PRN
• Ascorbic Acid 100mg/5ml  5ml OD
• Refer to Dr. Soriano
@ 10:15 am
• IVF d5 IMB 1000ml @ 50 ugtts, 24 hours
• Increase ampicillin to 350 mg IV q6h ANST
@ 16:00 pm
• For Bloodtyping

Physicians Order
Day 2
• Continue Meds/IVF
Physicians Order
Day 3
• Request for Typhidot
Physicians Order
Day 4
• Request for CBC with QPC
• VS q4h to include BP and record
Physicians Order
Day 5
• IVF to follow, same
Physicians Order
Day 6
• IVF to consume, D/C IV meds
• MGH
• Meds:
o Ascorbic acid 100ml/ 5ml  1 tsp OD
• Diagnosis Dengue Hemorrhagic Fever II resolving

X. COURSE IN THE WARD
In day 1, a 3-year old male patient carried by his mother was admitted with
a chief complaint of fever. Ten hours prior to consultation, the patient had a
high grade fever and vomiting for several hours according to the mother.
The patient had a high grade fever of 40.5 0
C and BP: 90/40. Diet as
tolerated was ordered. Upon assessment the patient is positive for
tonsillopharyngitis. . Anti-biotics was also part of his medication to treat his
tonsilopharyngitis. Ampicillin testing was done and had negative result. At
1000H, patient had a febrile seizure with temperature 41.80
C, Paracetamol
was given. Stool examination was requested and the fecalysis result was
normal, the stool was soft, yellow colored stool. At 0100H, the patient
experienced chills with temperature of 38.80
C. Paracetamol was given,
patient’s temperature went down to 370
C.
In day 2, the patient is slightly febrile with temperature of 37.60
C. The
mother was instructed to continue TSB and increase fluid intake.
In day 3, the patient is still febrile, Paracetamol via IV was given. Doctor
ordered for typhidot. The typhidot result were the following: IgG positive
and IgM negative. The patient is negative on typhoid fever.
In day 4, a significant drop in his temperature was noted, as low as 36.8 o
C
which is a sign that the patient is entering into the toxic stage of Dengue
Fever. This state of defervescence, is a period where the number of patient’s
platelet is at its lowest. It is at this time where his attending physician
ordered another Laboratory request for CBC and PC to check if Patient X’s
platelet count is below the normal range of 150,000 to 350,000 /L, which is
referred to as thrombocytopenia. Hemoglobin, hematocrit, RBC WBC and
Platelet count are within normal limits. Segmenters are slightly decrease
with the value of 0.36 which is below the normal value of 0.50-0.70. After
the significant drop of the client’s temperature, Patient X temperature were

elevated again for eight hours, a normal phenomenon for a DHF patient
before entering into the convalescent stage. The patient had general rashes
with itchiness.
In day 5, the patient is afebrile and positive for Herman’s sign.
In day 6, the patient is afebrile and still positive for Herman’s sign.
Additional medication was ordered Ascorbic acid with dosage of 100mg/5mL
to be taken 1 tsp everyday. Diagnosis of Dengue Hemorrhagic Fever II was
resolved. The patient was discharged.

XI. Drug Study
BRAND
NAME/GENERIC
CLASSIFICATION ACTION ROUTE&DOSAGE CONTRAINDICATIONS NURSING INTERVENTION
PARACETAMOL
Acetaminophen
Antipyretic Thought to
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.
Paracetamol
125mg/5ml PO –
5ml q4 RTC
Paracetamol
300mg/amp
IV – ½ ampule IV
PRN
- Contraindicated in
patients hypersensitive
to drug.
· Use cautiously in
patients with long term
alcohol use because
therapeutic doses
cause hepatotoxicity in
these patients.
· Hematologic:
hemolytic anemia,
neutropenia,
leukopenia,
pancytopenia.
· Hepatic: Jaundice
· Metabolic:
hypoglycemia
· Skin: rash, urticaria.
- Use liquid form for
children and patients who
have difficulty swallowing.
· In children, don’t exceed
five doses in 24 hours.
· Advise patient that drug
is only for short term use
and to consult the
physician if giving to
children for longer than 5
days or adults for longer
than 10 days.
· Advise patient or
caregiver that many over
the counter products
contain acetaminophen; be
aware of this when
calculating total daily dose.
· Warn patient that high
doses or unsupervised long
term use can cause liver
damage.

BRAND
NAME/GENERIC
AMPICILIN
Ampicillin
Anti-infective
Antibiotic
(Penicillin
Family)
Inhibits cell wall
synthesis during
microorganism
multiplication
Ampicillin: 130
mg IV q8h ANST
Children age 1
and older
weighing less than
40kg (88lb):
300mg/kg daily IV
in individual doses
every 6 hours.
Don’t exceed 4 g
daily .
- Contraindicated in
patients
hypersensitive to
drug or other
penicillins
.
- Use cautiously in
patients with other drug
allergies because of
possible cross sensitivity
- Before giving drug, ask
patient about allergic
reactions to penicillin.
However a negative
history of penicillin
allergy is no guarantee
against a future allergic
reaction
- Obtain specimen for
culture and sensitivity
test before giving first
dose. Therapy may
begin pending results.
-decrease dosage in
patients with impaired
renal function
- Don’t use IM route in
children
-Monitor liver function
test results during
therapy
- if large doses are given
superinfection may occur

BRAND
NAME/GENERIC
Ascorbic Acid Vitamins and
Minerals
Stimulates
collagen
formation and
tissue repair,
involved in
oxidation-
reduction
reactions
For extensive
burns, delayed
fracture or
wound healing,
severe febrile or
chronic disease
states
Oral liquid
100mg/5ml - 5ml
OD
Contraindicated in
patients with an
allergy to tartrazine
or sulfites. Large
doses are
contraindicated
during pregnancy
Protect solution from
light (IV) and refrigerate
ampules
For patient receiving Vit.
C, IM route may
promote better
utilization
Inform patient that Vit C
is readily absorbed from
citrus fruits, tomatoes,
potatoes and leafy
vegetables.

Assessment Nursing
Diagnosis
Inference Goal Intervention Rationale Evaluation
SUBJECTIVE:
“Kahapon pa siya
inaapoy ng lagnat”,
as verbalized by the
patient’s mother.
OBJECTIVE:
• Increase in body
temperature
above normal
range: 40.5 C
• Profused
Sweating
• Dry lips and
mucous
membrane
• Flushed skin
• Warm to touch
Hyperthermia
related to direct
effect of
circulating
endotoxins on the
hypothalamus,
altering
temperature
regulation.
Dengue Fever
Elevated WBC’s
Release of
endotoxins, that
cause disruption of
hypothalamic set
point
Increase in body
temperature
After 8 hours of
nursing intervention,
the patient will
demonstrate a
temperature within
the normal range,
free of chills and
associated
complications.
• Monitor patient
temperature (degree
and pattern) and note
shaking chills or
profused diaphoresis.
• Monitor
environmental
temperature; limit or
add bed linens as
indicated.
• Provide tepid
sponge baths; avoid
use of alcohol.
• Administer
antipyretics like
acetylsalicylic acid
(aspirin) and
acetaminophen
(Tylenol).
• Provide cooling
blanket.
• Temperature of
38.9 - 41.1 C
suggests acute
infectious
diseases process.
Fever pattern
may aid in
diagnosis.
• Room
temperature or
number of
blankets should
be alterd to
maintain near
normal
temperature.
• May help reduce
fever. Use of
alcohol may
cause chills,
actually elevating
temperature.
• Used to reduce
fever by its
central action on
the
hypothalamus.
• Used to reduce
fever usually
greater than 40
C when seizures
can occur.
Goal is met,
after 8 hours of
nursing
intervention, the
patient achieved
a temperature
within the
normal range as
evidenced by a
decreased in
body
temperature
from 40.5 C to
37 C. Patient
was also free of
chills and
associated
complications.

Assessment Nursing
Diagnosis
Subjective:
“Ayaw kumain ng anak
ko ”, as verbalized by
the patient’s mother.
Objective:
• Decreased tolerance
for activity
• Weakness
• Loss of muscle tone
• Weight upon
admission in
kilogram: 13
Imbalanced
Nutrition: less
than body
requirement
related to loss of
appetite
secondary to
dengue virus
Dengue Fever
Joint pain
Nausea,
vomiting
Anorexia
Decreased
appetite
After 3 days of
nursing
intervention,
patient will
demonstrate
stable weight and
will be free of
signs of
malnutrition.
Patient or mother
will demonstrate
behaviors or
lifestyle changes
to maintain
appropriate
weight.
Independent:
Assess causative/
contributing factor:
 Assess client's
weight, age, strength,
activity/rest level, and so
forth
 Assess nutritional
history, including food
preferences
 Observe and record
patient’s food intake
 Encourage client to
choose food that are
appealing to increase
appetite
 Avoid foods that
causes intolerance,
increase gastric motility
that results in epigastric
pain
 Provides
comparative baseline
 Identify
deficiencies, suggests
possible
interventions
 To monitor
caloric intake or
insufficient quality of
food consumption
 Toddlers eat a
lot of food that are
appealing to their
taste
 Foods such as
gas-forming, spicy,
too hot, too cold,
caffeinated
beverages can result
to epigastric pain
that will decrease
appetite leading to
weight loss
Goal is met, after
3 days of nursing
intervention,
patient
demonstrated
stable weight
and is free of
signs of
malnutrition.
Patient’s mother
also verbalized
and
demonstrated
behaviors and
lifestyle changes
to maintain
patient’s
appropriate
weight.

Dependent:
Establish a nutritional
plan that meets individual
needs:
 Avoid foods that
cause intolerances/
increase gastric motility
 Consult
dietitian/nutritional team
as indicated
 Provide nutritious
food and diet modification
as indicated.
 Small frequent
feeding with aspiration
precaution
 Promote pleasant,
relaxing environment
 Promote
adequate/timely fluid
intake
 Weigh as often as
possible and PRN
 Note occurrence and
report of constant sore
throat.
Family support:
Significant others should
provide positive regard,
love, and
acknowledgement in
 To enhance
intake
 To implement
interdisciplinary team
management
 To prevent
dehydration
 To monitor
effectiveness of
efforts
 Presence of
inflamed throat may
affect ability to
eat/lose of appetite

guiding client with eating
problem.

Assessment Nursing
Diagnosis
Subjective:
“Nanghihina at
nanglalambot sya.
Ni hindi nga nya
kaya umupo para
uminom ng gamot”,
as
verbalized by the
patent’s
mother.
Objective:
• Decreased
tolerance for
activity
• Greater need
for sleep and
rest
• Weakness and
fatigue
Activity intolerance
related to
generalized
weakness and
reduced energy
stores
Fever
Nausea and
vomiting
Anorexia
Decreased
appetite
Reduced energy
stores
Muscle weakness
and fatigue
After 8 hours of
nursing
intervention, the
mother will report a
measurable
increase in activity
tolerance
• Assess patient’s
ability to perform
normal tasks
noting complaints
of weakness and
fatigue
• Provide quiet
atmosphere,
uninterrupted rest
periods and
maintain bed rest.
• Implement
energy-saving
techniques like
sitting, rather
than standing,
when
administering oral
medications or
when providing
tepid sponge
baths.
• Influences
choice of
intervention and
needed
assistance
• Enhances rest
to lower body’s
oxygen
requirements
and reduces
strain on the
body
• Maximizes
available energy
for other tasks.
Goal is met after 8
hours of nursing
intervention,
patient’s mother
has reported a
measurable
increase in patient’s
activity tolerance as
evidenced by lesser
complaints of
fatigue and
weakness and by
increased tolerance
in activities like
sitting up to drink
medicines

Assessment Nursing
Diagnosis
Objective:
- Weakness and
irritability.
- Restlessness.
Laboratory Values:
Platelet count: 130/ L
Hct : 0.41%
Hgb: 13.6%
Risk for
injury/bleeding
related to
altered clotting
factor secondary
to the
coagulopathy
effect of dengue
virus
Dengue virus
Immune response
involving production
of cytokines and
chemokines
activation of T-
lymphocytes
vasculopathy,
increase capillary
fragility
disturbance of
hemostatic system
thrombocytopenia
and platelet
dysfunction
prolongation of PT
and PTT time
Severe bleeding
After 8 hours of
nursing
intervention, the
mother
of the client will
learn through
health teaching and
demonstration the
skills and practices
in preventing injury
to the patient that
will cause him to
bleed and to
identify the signs of
ongoing internal
bleeding
Independent:
- Assess for signs and
symptoms of G.I bleeding.
Check for
secretions. Observe color and
consistency
of stools or vomitus.
- Observe for presence of
petechiae, ecchymosis,
bleeding from one more sites.
- Monitor pulse,
Blood pressure.
- Note changes in mentation
and
level of consciousness.
- Avoid rectal temperature, be
gentle with GI tube insertions.
- Encourage use of soft
toothbrush, avoiding straining
for stool, and
forceful nose blowing.
- Use small needles for
injections. Apply pressure to
venipuncture sites for longer
than usual.
- The G.I tract
(esophagus and
rectum) is the most usual
source of bleeding of its
mucosal fragility.
- Sub-acute disseminated
Intravascular coagulation
(DIC) may develop
secondary to altered
clotting factors.
- An increase in
pulse with decreased
Blood pressure can
indicate loss of
Circulating blood volume.
- Changes may
Indicate cerebral
Perfusion secondary to,
Hypoxemia
- Rectal and
Esophageal vessels are
most vulnerable
to rupture.
- In the presence
of clotting factor
disturbances,
minimal trauma can
cause mucosal bleeding.
- Minimizes damage to
tissues, reducing risk for
bleeding and
hematoma.
Goal is met
after 8 hours
of nursing
intervention,
the mother
of the client
learned
through health
teaching and
demonstration
the skills and
practices in
preventing
injury to the
patient that
will cause him
to bleed as
evidenced by
providing soft
toothbrush to
the client and
mother also
identified the
signs of
ongoing
internal
bleeding as
evidenced by
frequent
observation of
the patients
stool color

- Recommend avoidance of
aspirin containing products.
Collaborative:
- Monitor Hb and Hct and
clotting factors.
- Prolongs coagulation,
potentiating risk of
hemorrhage.
- Indicators of
anemia, active
bleeding, or
impending
complications.

Assessment Nursing
Diagnosis
OBJECTIVE:
• Rashes on chest
area
• Mild scratching of
patient is observed
Risk for impaired
skin integrity
related to the
dengue virus as
evidenced by mild
scratching
Dengue virus
infection
Immunoglobulin
antibodies
attached to the
surface of mast
cells bind with an
antigen
Immune response
system is
activated
Histamine and
chemoctactic
substance are
released
Histamine causes
permeability of
blood vessels
and peripheral
vasodilation
Resulting to non-
specific febrile
illness with rash
After 8 hrs nursing
intervention the
patient will maintain
optimal skin integrity
as evidence by
absences of skin
breakdown
Independent:
• Assess for rashes
which may be present on
other areas of body
• Keep fingernails short
• Apply cold compress
or quick cold bath if not
contraindicated
• Maintain skin hygiene
using mild soap and
lukewarm water. Pat dry
skin gently and
thoroughly
• Encourage adequate
nutrition and hydration
• Hermans rash/sign
usually appears on the
upper and lower
extremities about 1cm
or less in size. Although
typically located in
extremities, unusual
manifestation of rash
may be generalized
classic rash. Itchiness
may be present at times
• To prevent skin
excoriation and
secondary infection
caused by scratching
• To ease and give
comfort to skin
itchiness. Cold
compress is
vasoconstrictor which
can reduce swelling
• Skin hygiene needed
to prevent secondary
infection and avoid
rubbing skin to prevent
skin breakdown. Avoid
harsh soaps that can
dry and cause skin
breakdown
• To promote healthy
skin
Goal is met after
8 hours of nursing
intervention, the
clients skin
integrity is not
impaired
as evidenced by
the client’s intact
skin that is free
from breakdown
and cuts

Assessment Nursing
Diagnosis
• Provide or advice
significant other to use
light clothing material
that is comfortable to the
client
• Use of baby powder
after bathing or cleaning
as indicated
• Remove wet and
wrinkled bed sheets
promptly. Keep bed
clothes dry, use non
irritating materials and
keep bed free of wrinkles,
crumbs etc
Collaborative:
• Administer anti-
itchiness as prescribe
• To prevent sweating
and keep the skin dry.
Sweat can potentiate
skin irritation and
scratching
• Moisture potentiates
skin breakdown. Dry,
crisp linen provides
comfort to the client
• To provide maximum
relief from itchiness
To relieve client from
itchiness

Assessment
Nursing
Diagnosis
Objective:
Length of Stay: 5
days (ongoing)
Admitted at Pediatric
Ward - sharing with
other sick clients in a
15 bed capacity room
Risk for
nosocomial
infection related
to prolonged
hospital stay
Dengue virus
Prolonged
hospitalization
(ongoing 5 days)
Exposure to
pathogens
Risk for nosocomial
infection
After an 8 hr of nursing
intervention, the client’s
significant others will
verbalize understanding
of desired
preventive/precautionar
y skills in maintaining an
aseptic environment to
the client
-Observe for localized signs
of infection at insertions sites
of invasive lines, sutures,
surgical incisions/wound
-Assess and document skin
conditions around insertion of
parenteral line
-Note signs and symptoms of
sepsis, fever, chills,
diaphoresis, altered level of
conciousness, positive blood
cultures
-Stress proper handwashing
techniques by all caregivers
-Monitoring of visitor to
prevent exposure of client
-Maintain sterile technique for
invasive procedure such as
IV line
-Review individual nutritional
needs, and adequate rest
-Emphasize the necessity of
taking antibiotics as directed
-Insertion sites of
invasive lines, sutures,
and surgical incisions are
the most common site of
infection
-Redness, swelling and
pain are the signs of
infection
-Early detection of
infection will result in
early diagnosis and
treatment
-Proper handwashing
lessen the transmission
of pathogens
-Visitors can transmit
pathogens to the client
-Infection can occur if the
sterility of the procedure
during IV insertion is
compromised
-Adequate rest and
nutrition helps maintain
stability of the body
therefore immune
system is not
compromised
-Completing the
medicated antibiotics will
treat the infection
Goal is met,
after an 8 hr of
nursing
intervention,
As evidenced
by the client
identifying/
practicing the
appropriate
behaviors and
skills in
maintaining an
aseptic
environment
favorable to
the client as
evidenced by
performing
frequent
handwashing
before and
after eating
and attending
to his child

XIII. HEALTH TEACHING
Medication
Intake of appropriate vitamin supplement to increase protection
mechanism of the immune system
Management
Management of such condition would be through hydration and doing
control measures to eliminate vector by promoting cleanliness in the
environment through proper disposal of rubber tires, changing water
of lower vases once a week, destruction of breeding places of mosquito
and residual spraying with insecticides.
Outpatient/Follow-up
Any odd signs such as fever, petechiae, recurrence of fever, etc. must
be immediately reported to the physician
There is no vaccine available to prevent dengue fever. Use personal
protection such as full-coverage clothing, netting, mosquito repellent
containing diethylmetatoluamide (DEET), and if possible, travel during
periods of minimal mosquito activity. Mosquito abatement programs
can also reduce the risk of infection.

References:
Suzanne C. Smeltzer Brenda G. Bare, Brunner & Suddarths’s Textbook
of Medical Surgical Nursing, 10th
Edition, 2004
Frances Prescilla L. Cuevas, RN MAN, Public Health Nursing in the
Philippines, 10th
Edition 2007
Catherine Paradiso, Lippincot’s Review Series – Pharmacology, 1998
Websites:
http://www.merck.com/mmpe/sec14/ch191/ch191b.html#sec14-
ch191-ch191b-2577
http://doh.gov.ph/
http://www.webmd.com/video/travel-dengue-fever

236750009 dengue-case-study1

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