Pamantasan ng Lungsod ng Marikina

J.P. Rizal St. Concepcion Uno, Marikina City

__________________________

DENGUE FEVER

__________________________

An Individual Case Study

In Partial Fulfillment

of the Requirement for the Course

NCM 101

RLE

St. Victoria Hospital

Submitted by:

TABLE OF CONTENTS

I. Introduction………………………………………

……….………………… 1

II. Objectives with specific

objectives……………………….…………….

3

• General Objective

• Specific Objective

III. Theoretical Foundation (Nursing theory)

……………………………… 4

IV. Nursing History……………………………………………….…………… 5

a. Biographical Data

b. Reason for seeking health care

c. History of present illness

d. Past health History

e. Family genogram…………………………………………………………… 6

f. Social History

V. Immunization/Exposure to communicable

disease………………… 7

VI. Allergies

VII. Home Medication/ Alternative medicine

VIII. Developmental Level

IX. Pediatric

History……………………………………………

…………… 8

a. Developmental Milestone

X. Anatomy and

Physiology………………………………………

….….. 9

XI. Pathophysiology (client based)

………………….…………………….

11

XII. Gordon’s functional

pattern……………………………………………

12

XIII. Physical

Assessment………………………………………

…………… 14

XIV. Diagnostic/Laboratory

Examinations………………………………...

17

XV. Medical

Diagnosis…………………………………………

…………… 23

XVI. Drug

Study………………………………………………

………………. 24

XVII. Nursing care

plan………………………………………………

……… 27

XVIII. Discharge

plan………………………………………………

…………. 31

XIX. References………………………………………

……………………… 32

I. Introduction

Dengue is one of the most common mosquito-borne viral diseases. The first and

second epidemics of Dengue hemorrhagic fever occurred in Manila in 1954 and 1956,

followed by the third in Bangkok in 1958. Since then, Dengue has spread throughout

tropical Asian countries and has expanded globally. Dengue virus belongs to the

flavivirus genus of the Flaviviridae family. They are transmitted among humans by

Aedes mosquitoes bite such as Aedes aegypti. There are four serotypes, namely

Dengue type 1, Dengue type 2, Dengue type 3 and Dengue type 4. Infection with any of

the four serotypes causes clinical symptoms that may vary in virus virulence, and host

response. And recovery from one infection provides life- long immunity against that

particular serotype. Dengue has its progression from Dengue fever, which is a simple

form of dengue it may lead to dengue hemorrhagic fever, a condition which involves

sensitive stomach, petechial, weak pulse, and internal bleeding that can lead to black

vomit or feces. If dengue hemorrhagic fever is untreated it may progress to dengue

shock syndrome, a worst form of dengue which can also result to death.

According to World Health Organization (WHO), each year an estimated 100

million cases of dengue occur worldwide, about 2.5 billion people living in tropical and

subtropical areas are at risk. The National Epidemiology Center of the Philippines'

Department of Health reports a total of 132,046 dengue cases from January to 13

October 2012. This is 24.92% higher compared to the same time period in 2011. Region

III and Region IV-A registered the highest number of cases, about 30% of these cases,

may progress to dengue hemorrhagic fever or dengue shock syndrome and an

estimated 10% will eventually lead to death. The global prevalence of dengue has

grown dramatically in recent decades. The disease is now endemic in 100 countries of

Africa, the Americas, the Eastern Mediterranean, Southeast Asia and the Western

Pacific.

There is no specific treatment for dengue fever, dengue hemorrhagic fever, and

dengue shock syndrome but this can be treated by timely supportive therapy to

undertake circulatory shock due to hemoconcentration (plasma leakage) and bleeding. 1

Close observation of vital signs by the attending physician and nurses with frequent

clinical and laboratory monitoring especially in critical point. Adequate fluid replacement

is also necessary to overcome the plasma leakage. Intravenous infusion is also helpful

to rehydrate especially if the patient is not able to maintain oral intake. For reducing

fever, frequent tepid sponge bath and paracetamol are provided. Aspirin and non-

steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are contraindicated

because these may worsen the bleeding tendency and might cause some infections.

Acetaminophen and paracetamol can be taken under the prescription of the doctor.

I chose these case because I was motivated to study this globally common,

yearly problem of most of the country in Asia. By this, I will be able to discover its

process, how it is being acquired, the pathophysiology and clinical manifestations which

are being experienced by my patient. By doing so, I am able to fructify my knowledge,

enabling me to know the appropriate nursing care for my patient. This study would help

me as a student nurse to comprehend not only the disease mentioned but also for the

commonalities and differences among other diseases for the betterment of this study.

2

II. Objectives with specific objectives

General Objective:

At the end of the study, the student will be able to improve not only the knowledge

in the disease process and clinical manifestations but also on how to give necessary

intervention indicated to the patient. By this, we will be able to hasten our knowledge,

skills, and attitude in giving appropriate nursing care for the patient. Through thorough

research and interview, we can acquire concrete and necessary information about

Dengue Fever.

Specific Objectives:

1. To establish rapport with my client and her significant others to gain good

working relationship for the success of this case study.

2. Present reasonable introduction that will provide an overview of the disease and

can be an eye-opener of information for the readers.

3. Conduct thorough physical assessment of the patient in cephalocaudal manner

to note other problems of the patient to be managed.

4. Discuss the anatomy and physiology of the affected system to have a

background regarding the organ affected by the disease.

5. Provide necessary nursing care plan to prioritize the immediate problem of the

patient.

6. Provide comprehensive discharge plan of the patient to ensure the continuation

of the management of the disease even after discharge.

3

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III. Theoretical Foundation (1) Nursing theory

According to Florence Nightingale’s Environmental theory, ventilation is

important because a person who breathes his own air repeatedly would become

sick. She also said that we should maintain cleanliness because it is important in

quick recovery of the patient. Effective drainage is also necessary because this

will help in preventing the breeding of the epidemic diseases. And pure water is

also important because when epidemic disease shows itself, safe water is

needed to avoid infection and to ensure your health safety. The case of DG can

be associated with Florence Nightingale theory, wherein, clean environment

plays an important role in rejuvenating the patient’s optimum level of health.

According to the mother, they have uncovered stocked water outside their house

and due to continuous raining they’ve suspected that it is one of the reasons why

her daughter got the disease. Having a clean, quiet, and well- ventilated

environment, also an effective drainage and pure water will help the body to

restore more quickly.

5

IV. Nursing History

A. Biographical Data

This is a case study of DG, a 6 years old girl who lives in Guitnang Bayan,

San Mateo Rizal. Her mother is a Grade 4 teacher in San Mateo Elementary

School. She was born in Quezon City on the date of August 30, 2007. Her parents

are the ones who supported her in hospital bills. Her mother is the one who

brought her to the hospital last September 2, 2013 @6pm under the supervision of

Dra.Ordonez.

B. Reason for seeking Health Care

She was experiencing intermittent fever of 390C for the past 3 days so her

mother decided to take her to the hospital for check-up.

C. History of Present Illness

According to the mother, three days prior to admission, her daughter had a

positive intermittent fever of 390C. What she did was to self-medicate her daughter

with paracetamol for three consecutive days, but the patient was still having fever

which led them to the hospital for check- up with Dra. Ordonez who had also

advised them to have patient admitted.

D. Past Health History (PHH)

My patient had pneumonia when she was two years old and had been

admitted and stayed to the hospital for 1 and a half month. As far as the mother

recalled, her daughter took medicine like amoxicillin.

Patient DG

E. Family Genogram

Lolo (63) Lola (60) Lolo (62) Lola (59)

HPN HPN DM DM

A&W A&W A&W A&W A&W A&W A&W A&W

34 y/o 33y/o 32y/o 31y/o 30y/o 29y/o 33y/o 35y/o

F. Social History

Patient DG is the only Child of Ms.AG. She is in her school age. Patient

DG loves to play computer games at home; she does her homework first before

playing games. According to her mother she sometimes plays outside their

house with her friends.

6

Legend:

Female Male

Alive and well Female Alive and well Male

Unhealthy Female Unhealthy Male

MOTHER SIDEMOTHER SIDE FATHER SIDEFATHER SIDE

V. Immunization/ Exposure to communicable Disease

Patient DG had completed her immunization when she was a child. She

received DPT, OPV, Hepatitis vaccine, Anti-measles vaccine and BCG from the

Barangay health center. She did have pneumonia when she was 2 years old.

VI. Allergies

Patient DG doesn’t have any allergies to any food, dust, drugs or

anything according to the mother.

VII. Home Medications/Alternative Medicine

According to the mother when her daughter catches up cold and cough

she usually gave her herbal medicine like oregano juice with calamansi extract,

and it is effective to her. For fever, she usually gave paracetamol.

VIII.Developmental Level

Patient DG is in her School-age level (6-12 y/o). According to Erik

Erickson (Psychosocial theory), patient DG’s developmental task is to form a

sense of industry vs. inferiority. Child learns to do things well. Patient DG was

able to write her name correctly, she can also read paragraphs. According to her

mother she allows patient DG to do her homework on her own, and when patient

DG is done with it, she allows her to play computer games for her reward.

7

IX. Pediatric History

a. Developmental Milestone

According to Maternal and child nursing care book, Lippincott

William and Wilkins, volume two, pp 915, a school- age person treats her

teacher as the authority; adjustment to all-day school may be difficult and

lead to nervous manifestations of fingernail biting. Also, a six years old

child can walk on a straight line because they have enough coordination.

Patient DG was able to show industry instead of inferiority especially in

doing school works. She can easily tie her shoelaces, read, and write.

According to her mother, she can also shade coloring books with minimal

error, can fold and cut paper into simple shapes.

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XII. Gordon’s Functional Pattern

PATTERN

BEFORE

HOSPITALIZATION

DURING

HOSPITALIZATION ANALYSIS

Health Perception

Dati po masigla ako,

pumapasok sa school

at naglalaro ng

computer games

Di na po ako

makapasok sa school

kasi may sakit ako

Due to her illness

Nutritional

Metabolic

She eats 3x a day,

loves to eat processed

foods such as tocino,

meatloft, hotdog. She

seldom eats

vegetables and drinks

6-8 glasses of water.

Mostly eat bread and

fruits. She drinks 6-8

glasses of water a day.

The doctor ordered

diet as tolerated

(DAT) to the patient

and except dark

colored food (EDCF)

Elimination

She is able to urinate

(3x a day) and

defecate (1x a day)

normally every day.

She usually defecate

early in the morning

before going to school

without any problem

She is able to urinate

(3x a day) and defecate

(1x a day) normally

every day.

Her condition doesn’t

affect her elimination

pattern.

Activity/Exercise

Her daily routine is

going to school, doing

home works then

playing computer

games

She interacts with her

auntie, mother and

visitors.

She only focuses on

simple things.

Sleep/Rest Matagal po ang tulog

ko, minsan 8-9 hours

Nagigising po ako

minsan.

This may be due to

giving of medication.Cognitive/

Perceptual

There is no problem in

her senses.

She can comprehend

well. Responses to

physical and verbal

There is no problem in

her senses. She is

responsive but shy

when asked.

Adjusting to

environment

12

stimuliRole-Relationship She is the only child

and source of joy and

strength of her parents.

She is the only child

and source of joy and

strength of her parents.

But also stress because

she is sick.

Due to her condition

she can’t perform her

role in her parents.

Sexuality-

Reproductive

She doesn’t fully

understand about

having a

boyfriend/married

Same Due to her youthful

mind, it is still not her

priority in life.

Coping/Stress

Tolerance

She doesn’t fully

identify stressors

Same She is still in a playful

mind and doesn’t

mind stressors of life.Values/Beliefs She is a Born-Again

Christian. She goes to

church every Sunday

Due to parents

influence

13

XIII. Physical Assessment

Name: DG

Age: 6y/o

Date of assessment: Sept. 6, 2013

BODY PARTS NORMAL FINDINGS ACTUAL FINDINGS ANALYSISSkin Uniform color, except

in the areas exposed

to the sun, no edema

present and no other

lesions

Equal distribution of color,

no lesions, (-) turgor, rash

present in in right foot.

Rash may be due to

increase of blood

pressure in the

vessel.

Hair Evenly distributed hair,

thick hair, no infection,

and no presence of

dandruff, silky and

resilient hair.

Hair is black in color, no

evidence of alopecia,

evenly distributed hair, (-)

pediculosis and dandruff

Normal findings

Head/Scalp Rounded, smooth skull

contour, absences of

nodules and masses;

has systematic facial

features and

movements.

There is no

lumps/masses, no lesions,

smooth skull contour

Normal findings

Eyes Eyebrows and

Eyelashes are evenly

distributed, the eyelids

has no discharge and

no discoloration; pupils

are black in color;

round, equal in size

normally 3-7 mm in

diameter; conjunctiva

pink in color, the sclera

are white in color.

Eye brows and eye lashes

are evenly distributed,

eyes are dark brown in

color, Sclera is white in

color, (+) light

accommodation, pupils

are black in color and

equal in size, no lesions or

discharge in conjunctiva

and is pink in color

Normal findings

Ears Color same as facial Color same as facial skin, Normal findings14

skin, symmetrical,

auricle aligned with

outer cantus of eyes

about 10º from vertical,

not tender; pinna

recoils after it is folded

able to hear sound in

both ears.

symmetrical auricle

alignment with outer

cantus of eyes. (+) ear

wax, pinna recoils after it

is folded and able to hear

sound in both ears.

Nose Symmetric and straight

no discharge or flaring,

uniform color. No

tenderness and no

lesions.

No discharge, symmetrical

and straight alignment,

uniform in color. No

tenderness and lesions

Normal findings

Lips/Mouth Lips pink in color, soft,

moist, smooth texture,

ability to purse lips; the

teeth are smooth,

white, firm texture to

the gums. Tongue is in

central position, pink in

color moist.

(-) dryness, teeth are

intact, no inflammation in

uvula and tonsil, tongue is

in central position

Normal findings

Neck Muscle equal in size;

head centered; head

movement is

coordinated and in

smooth movement. No

enlarge lymph node.

Uniform in color, no

lumps/masses, no pain

when swallowing, head

centered

Normal findings

Chest Quiet, rhythmic

respiration, normal

breathing rate, no

retraction when

breathing

No retractions when

breathing, no use of

accessory muscle used

when breathing,

symmetrical chest

movement

Normal findings

15

Abdomen Uniform color, no

evidence of enlarged

liver or spleen. Audible

bowel sounds,

absence at arterial

bruits, and absence at

friction rubs, no

tenderness.

Uniform in color, skin

intact, soft, no tenderness,

(+) borborygmi sound.

Normal findings

Extremities Convex curvature,

angle of nail plate

160º, smooth texture,

when performing the

blanch test of capillary

refill it is prompt return

of usual color. (2-3

sec)

Uniform in color, no

fractures, symmetrical in

movement, has some rash

in right foot, nail beds are

pink in color, capillary

refills at 2-3 seconds

Rash may be due to

increase of blood

pressure in the

vessel.

16

XIV. Diagnostic/Laboratory Examination

Physician: Dr. Chanyungco Date: Sept. 2, 2013

Examination Normal

Values

Actual

Findings

Significance

Hematology

ReportWBC 5.0-10.0x109/L 3.0 Decrease due to inadequate

inflammatory response defense to

suppress infection and anti-body

mediated immunity takes place.RBC 4.2-5.6x1012/L 4.8 Normal

Hemoglobin 140-180g/L 130 Decreased hemoglobin results in RBC

destruction or infiltration of bone marrow

with the infectious cell.Hematocrit 0.37-0.47 0.41 Normal

Platelet 150-400x109/L 167 Normal

WBC Differential

CountSegmenters 0.40-0.60 0.85 Increased due to infection, it attack and

kill infectionsLymphocytes 0.20-0.40 0.13 Decreased due to debilitating illness,

humoral immune response to take place.Monocytes 0.02-0.05 0.02 Normal

CBC with Platelet

Hemoglobin 125-160g/dl 120 Decreased hemoglobin results in RBC

destruction or infiltration of bone marrow

with the infectious cell.Hematocrit 0.38-0.54 0.37 Decreased results in RBC destruction or

infiltration of bone marrow with the

infectious cell.WBC 4.5-10.0x109/L 1.70 Decrease due to inadequate inflammatory

response defense to suppress infection

and anti-body mediated immunity takes

17

place.RBC 4.2-6.2x1012/L 4.20 NormalWBC Differential

CountSegmenters 0.46-0.66 0.33 Decreased due to inadequate protection to

an ongoing infection because it acts as

phagocytes and first to arrive in infected

site.

Lymphocytes 0.20-0.40 0.70 Decreased due to debilitating illness,

humoral immune response to take place.Platelet 150-400x109/L 229 Normal

Leah Tolentino Alsol, Mennen

Med. Tech Pathologist

Lab Result

Examination: Dengue NS1 Significance

Specimen: Blood Dengue NS1 an antigen tests (NS1 stands for

nonstructural protein 1), full name is Platelia Dengue

NS1 Ag assay, is a test for dengue. It allows rapid

detection on the first day of fever, before antibodies

appear some 5 or more days later.

Dengue NS1: Positive (+)

Clinical Result

Date: Sept. 3, 2013

Urinalysis Normal findings Actual findings AnalysisColor Normal urine is a transparent

solution ranging from colorless

to amber but is usually a pale

yellow.

YellowNormal findings

Transparency The turbidity of the urine sample

is clear, slightly cloud, cloudy,

opaque. Normally, fresh urine is

slightly cloudy.

Slightly turbid Normal findings18

Specific Gravity Normal urine density or values

vary between 1.003–1.035

(g·cm−3)

1.030 Normal findings

pH The pH of urine can vary

between 4.6 and 8, with neutral

(7) being norm

(6) Acidic Acidic pH helps in

preventing bacterial

growth

WBC 0.2/hpf 6-8/HPF Presence of

infectionRBC 0.2/hpf 1-3/HPF May be due to

bladder problem

Bacteria Absent Moderate Presence of

infection

Epithelial Cells Absent few Possible

contamination of the

specimen

E Examination Normal

Values

Actual

Findings

Significance

CBC with Platelet

Hemoglobin 125-160g/dl 130 NormalHematocrit 0.38-0.54 0.40 NormalWBC 4.5-10.0x109/L 2.5 Decrease due to inadequate

inflammatory response defense to

suppress infection and anti-body

mediated immunity takes place.RBC 4.2-6.2x1012/L 4.55 NormalWBC Differential

Count

Normal

Values

Actual

Findings

Significance

Segmenters 0.46-0.66 0.38 Decreased due to inadequate

protection to an ongoing infection

because it acts as phagocytes and

first to arrive in infected site.

Lymphocytes 0.20-0.40 0.62 Increase immune response fighting

infection

19

Platelet 150-400x109/L 175 Normal

Date: Sept. 4, 2013

E Examination Normal

Values

Actual

Findings

Significance

CBC with Platelet

Hemoglobin 125-160g/dl 130 NormalHematocrit 0.38-0.54 0.40 NormalWBC 4.5-10.0x109/L 1.80 Decrease due to inadequate

inflammatory response defense to

suppress infection and anti-body

mediated immunity takes place.RBC 4.2-6.2x1012/L 4.55 NormalWBC Differential

CountSegmenters 0.46-0.66 0.42 NormalLymphocytes 0.20-0.40 0.58 Increase immune response fighting

infectionPlatelet 150-400x109/L 178 Normal

Clinical Result Date: Sept. 5, 2013

Urinalysis

Urinalysis Normal findings Actual Findings AnalysisColor Normal urine is a transparent

solution ranging from

colorless to amber but is

usually a pale yellow.

Yellow Normal findings

Transparency The turbidity of the urine

sample is clear, slightly cloud,

cloudy, opaque. Normally,

fresh urine is slightly cloudy.

Clear Normal findings

Specific

Gravity

Normal urine density or values

vary between 1.003–1.035

(g·cm−3)

1.005 Normal findings

pH The pH of urine can vary (6)Acidic Acidic pH helps in

20

between 4.6 and 8, with

neutral (7) being norm

preventing bacterial

growth

WBC 0.2/hpf 1-2/HPF Presence of infection

RBC 0.2/hpf 0-3/HPF May be due to

bladder problem

Bacteria Absent Few Presence of infection

Epithelial Cells Absent Few Possible contamination of the specimen

E Examination Normal

Values

Actual

Findings

Significance

CBC with Platelet

Hemoglobin 125-160g/dl 116 Decreased hemoglobin results in RBC destruction or infiltration of bone marrow with the infectious cell.

Hematocrit 0.38-0.54 0.36 Decreased results in RBC destruction or infiltration of bone marrow with the infectious cell.

WBC 4.5-10.0x109/L 1.1 Decrease due to inadequate inflammatory

response defense to suppress infection

and anti-body mediated immunity takes

place.RBC 4.2-6.2x1012/L 4.06 Decreased due to destruction of RBC or

infiltration of bone marrow with infectious

cellWBC Differential

CountSegmenters 0.46-0.66 0.37 Decreased due to inadequate protection

to an ongoing infection because it acts as

phagocytes and first to arrive in infected

site.

Lymphocytes 0.20-0.40 0.63 Increase immune response fighting

21

infectionPlatelet 150-400x109/L 211 Normal

Clinical Result

Serology for typhidot

IgM (-) IgG(-)

Clinical Interpretation

Results Clinical InterpretationIgM (+) Acute typhoid feverIgM &IgG (+) Acute typhoid fever (in the middle stage of infection)IgG (+) Implication for the presence of IgG antibodies infection (in which case

current fever may not be due to typhoid)IgM & IgG (-) Probably not typhoid

Date: Sept. 6, 2013 @9am

E Examination Normal

Values

Actual

Findings

Significance

CBC with Platelet

Hemoglobin 125-160g/dl 120 Decreased hemoglobin results in RBC destruction or infiltration of bone marrow with the infectious cell.

Hematocrit 0.38-0.54 0.37 Decreased results in RBC destruction or infiltration of bone marrow with the infectious cell.

WBC 4.5-10.0x109/L 2.10 Decrease due to inadequate inflammatory

response defense to suppress infection and

anti-body mediated immunity takes place.RBC 4.2-6.2x1012/L 4.20 NormalWBC

Differential CountSegmenters 0.46-0.66 0.40 Decreased due to inadequate protection to

an ongoing infection because it acts as

phagocytes and first to arrive in infected

site.

Lymphocytes 0.20-0.40 0.60 increase due to increase immune response

fighting infectionPlatelet 150-400x109/L 250 Normal

XV. Medical Diagnosis: Dengue Fever

23

XVIII. Discharge Plan (use METHODS format)

M-edicine • Advise the relatives to continue the prescribed

home medications to ensure optimum recovery.

E-xercise • Provide a clean environment

• Use screens or mosquito nets when sleeping

• Do not stock water without cover to avoid

mosquito breeding. T-reatment • Instruct patient or parents to increase fluid intake

• Instruct patient or parents to have complete bed

restH-ealth Education • Advise the parents to use insect repellants

• Use also insecticides in the house once in a

month

• Maintain good hygiene by taking a daily bathO-ut patient Dep’t

(Check-up)

• Instruct patient to continue follow-up check up to

the doctor.D-iet • Eat healthy foods such as fruits, vegetables, and

meat

• Drink a lot of water, at least 8-10 glasses of water

a dayS-pirituality

• Advise patient to maintain good and safe

environment

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