CASE PRESENTATION

Dengue Hemorrhagic Fever

Presented by: Vernalin B. Terrado

Dengue Hemorrhagic Fever

General Objectives:

• The ultimate purpose of this study is to refresh the learned concepts about dengue hemorrhagic fever and to develop the understanding on the particular disease in accordance with further research and presentation based on the patients situation.

Specific Objectives:

This case presentation seeks to provide different information about the disease to be presented and about the client being considered with the following specific objectives:• Give a brief introduction about Dengue

hemorrhagic fever together with its signs and symptoms.

• Discuss the theoretical framework that is related to the client’s condition.

• Present the client’s demographic data and health history with its Gordon’s pattern of functioning.

• Present the abnormal results of the Physical Assessment made on the client.

• Present the different laboratory results or test done to the client with its interpretation.

• Discuss the normal Anatomy and Physiology of the Blood.

• Explain the Pathophysiology of Dengue Hemorrhagic Fever

• Discuss the drugs prescribed to the client by a Drug Study.

• Present an appropriate Nursing Care Plan for the most prioritized problem.

• Give a Discharge Plan that the client may use upon discharge to the hospital

Introduction:Dengue hemorrhagic

fever is an acute febrile diseases found in tropics.It is a complication of Dengue fever with hemorrhages. It is characterized by abnormal vascular permeability, hypovolemia and abnormal blood clotting mechanism.

The Dengue virus type 1,2,3,4, along with other arboviruse which are chikungunya, O’ nyong-nyong, west nile and flavi virus are classified as the causative agents. The vector responsible for the transmission of the virus is the domestic, day- biting mosquito known as the Aedes aegypti.The vector responsible for the transmission of the virus is the domestic, day-biting mosquito known as the Aedes aegypti.

Clinical manifestations according to its grade

are persistent high fever, complains of pain,

nausea and vomiting, and pathological

vascular changes which is classified as

Grade I, Grade II is persistence of signs and

symptoms of Grade I with bleeding while

Grade III has additional signs of circulatory

failure and Grade IV with signs and

symptoms of hypovolemic shock that can lead

to death.

Diagnostic test used to determine DHF are Rumpel

leads test otherwise known as Tourniquet test and

platelet count test that is shown in hematology

examination.Treatment is mainly symptomatic and

supportive.

Theoretical Framework:Nightingale's core nursing

theory has an environmentalfocus: It was her belief that theenvironment is an alterablemedium that can be used toimprove the conditions ofNature and encourage healing.Ventilation, clean air, cleanwater, control of noise,provision for light, andAdequate waste managementare just a some of the elementsShe believed could beMonitored and improved whennecessary.

Nightingale’s theory addresses the prevention of occurrences of Dengue Hemorrhagic Fever. In facilitating proper environmental sanitation we can achieve a surroundings with no presence of any vector that cause its transmission as they can no longer exist if the environment is not suited for their survival hence decreasing the morbidity rate of Dengue in our country.

We should be knowledgeable on how to keep our surroundings free from any breeding sites that could serve as a reservoir for the mosquito. As a nurse we should teach our clients how to do proper water storage and environmental sanitation so as to prevent disease occurrence and recurrence.

Comprehensive History:Biographic Data:

• Name: E.D.B• Date : 7-21-09 • Time of Admission 10:45 AM• Unit/Room: Pedia isolation

room• Address: Norzagaray,

Baliuag, Bulacan• Age: 8 y/o• Gender: Female• Status: N/A

• Religion: Roman Catholic

• Citizenship: Filipino

• Birth date: February 25, 2001

• Birthplace: OLSJDM

• Attending Physician:

• Final Diagnosis: DHF III

• Working Diagnosis: DFS I

• Chief Complaint: Abdominal pain with vomiting

Nursing History

Past Medical History

According to her mother the patient doesn’t experience any illness before that they treat of as an immediate concern aside from developing UTI when she was 5 years old. The patient only experienced having common cough and colds occasionally. She also experiences fever before and it was relieved by over the counter drugs and rest. Their family don’t seek consultation for regular health check up. She hasn’t been hospitalized and only seeks consultation to their Baranggay Health center whenever any health problem arises. She doesn’t also receive an immunization vaccine for measles.

History of Present Illness:Five days prior to admission the client suffers

from having a high fever with a temperature of 39. 4 degrees celcius, Paracetamol was given for relief. After three days the fever subsides and abdominal pain and vomiting of brownish colored vomitus takes place which prompted her hospitalization.

Upon admission the child have experienced gum bleeding and have presence of petechiae over the face and lower extremities accompanied by fatigue and loss of appetite. Hematology examination shows low platelet count with a value of 80 mm3.

During the interview session she has a fever and experiences no bleeding at all. Her abdominal pain also ceases.

Family History:

According to the mother of the patient

They only have history of hypertension on her

mother side in their family while she doesn’t

have any knowledge about the health history

in the side of his husband.

They claim to have suffered from no

serious illness though they sometimes

experiences common illnesses within the

members of their family.

Activities of Daily Living

Gordon’s Functional Health Patterns

a. Health Perception and Health Management Pattern

The patient sees her pattern of health as normal as she suffered from no serious illnesses before. She manages her health by following her mothers instructions such as sleeping early and eating foods on regular basis. She also follows proper personal hygiene for her to become healthy.

b.Nutritional and Metabolic Pattern

The patient usually eatsVegetables because theyhave many of it planted intheir backyard. She said thather favorite food is junkFoods especially chips andSalty foods. She is also fondof eating sweets such aschocolates and candies. SheUsually drinks up to 6glasses of water a dayincluding other beverages. Sheis not taking any vitaminSupplements.

Breakfast One (1) cup of rice, fried egg with fried eggplant and a glass of chocolate drink.

Lunch One (1) cup of rice, menudo and a glass of water.

Dinner One (1) cup of rice, a slice of fried fish a glass of water.

The following is her 24hour diet recall.

c. Elimination Pattern

She move her bowel

twice a day with the usual

color of light brown that

occasionally change

In accordance with her

Choices of foods. She also

urinates 4-5 times a day

which has light yellow

color.

d. Activity-Exercise Pattern

The usual activity

pattern of the patient

involves her activities of

daily living, going to school

and helping in light

household chores. Her

hobbies are watching TV

and reading story books

She spends most of her

time playing outside with

her cousins and friends.

e. Sleep-Rest Pattern

The client doesn’t have

any difficulty in sleeping

pattern. She sleeps at

around 8 in the evening and

wake up early. She doesn’t

have the habit of sleeping at

daytime. She usually drinks

Milk before she goes to

Sleep and she usually

sleeps at about 10 hours

daily.

f. Cognitive-Perceptual Pattern

The patient is able to

read and write. She is

currently in grade two in

elementary education

and portrays a sharp

memory when asked

about past experiences and

significant others. She also

has good eyesight

and has a normal

functioning for her

senses and perception.

g. Self-Perception and Self Concept Pattern

She verbalizesSatisfaction with herabilities and talents. SheAlso describe herself as aVery jolly person thoughshe is sad during theInterview because of herCurrent condition. With thehelp of her Mother she wasable to answer most of myquestions. She has goodbody posture and was ableto maintain eye contactupon interview.

h. Role-Relationships Pattern:

She is the youngest

among her siblings. She

helps the other family

members by doing and

following little tasks

whenever they ask her to

do so. The patient has a

good family relationship. She

state that she is happy with

them and they care and love

her so much. The significant

people in clients life is her

mother.

i. Sexuality-Reproductive Pattern

This pattern is not

asked because this is not

applicable to the patient

due to clients age.

j. Coping-Stress Pattern:

As a child she also

deals with some of stressful

events everyday. When

she was in school her

teacher helps her with

her study and school

works. She manage her

problems with the help of

the significant others. Her

Status now being sick is one of

The greatest stressor for the

client and she was able to

cope up because of their aid.

k.Values-Belief Pattern:

The client is a catholic

and she usually goes to

church every Sunday

with her family. She state

that being polite to them and

Following elderly them is an

Important value for her. She

Usually prays at night before

she goes to sleep. She believed

That God is always with her

And would never leave her no

matter what happens..

V. Physical Assessment

BP: 100/90 mmhg PR: 78 bpmTemperature: 38.6 degrees celcius RR: 18 bpm

BODY PARTS TECHNIQUE USED NORMAL FINDINGS

ACTUAL FINDINGS ANALYSIS

A. SKIN Inspection, palpation Varies from light to deep brown, from ruddy pink to light pink, from yellow overtones to olive, generally uniform skin temperature.

Dark brown in color complexion with some presence of wounds and abrasions in the extremities of the client. No nodes or mass elevation can be palpated.. Hot to touch and flushing skin.

-Indicates impaired skin integrity.-Hyperthermia

B. HAIR Inspection Thick, silky, resilient, free from infestation, evenly distributed and covers the whole scalp.

Thick and sticky with presence of some lice.

Improper personal hygiene.

C. NAILS Inspection, Palpation Convex curvature smooth texture, highly vascular and pink, prompt return of pink less than 3 seconds.

Convex curvature smooth texture, highly vascular and light pink to pale in color. Capillary refill after 2-3 sec. Nails have deposition of dirt in its tips and sides.

An indication of improper hygiene.

D. NECK REGION Inspection, palpation Symmetrical and straight, no palpable lumps, and supple, trachea is on midline of neck, and spaces are equal on both sides.

Symmetrical and straight, with palpable lymph nodes

Due to presence of infection

E. LUNGS Auscultation Symmetrical chest expansion, clear breath sounds.

Symmetrical chest expansion, Crackles sound heard upon auscultation. Dyspnea is not observed.

Not normal. Crackles sound is due to pleural effusion.

F. HEART Auscultation Normal rate, regular rhythm, no murmur.

No palpitation, no murmur

Normal

G. PERIPHERAL Palpation Symmetrical pulse volume, full pulsation.

Symmetrical pulse volume, full pulsation.

Normal

H. BREAST Inspection, Palpation Round shape, slightly unequal in size, generally symmetrical, no tenderness, masses, nodules or nipple discharge.

Symmetrical, with no protuberance elevation.

Normal

I. ABDOMEN Inspection, Auscultation, Percussion,Palpation

Uniform color, rounded symmetrical contour, audible bowel sounds, tenderness, liver and bladder are not palpable.

No scars seen upon inspection. Uniform in color, audible bowel sounds.

Normal

J. VAGINA Inspection No inflammation, swelling or discharge.

No inflammation, swelling or discharge.

Normal

K. UPPER AND LOWER EXTREMITIES

Inspection Equal size on both sides of the body, weakness on the lower and upper extremities.

Equal size on both sides of the body. An ongoing IVF of D5LR hooked @ right arm regulated at 35 gtts/min. Lymph nodes in the Axilla and groins are palpable. Noticeable presence of wounds on the lower right extremity and both forearm.

Not normalPalpable lymph nodes indicates infection. Wounds indicates impaired skin integrity.

1. SKULL Inspection, Palpation Proportional to the size of the body, round with prominences in the frontal and occipital area, symmetrical in all places.

Proportional to the size of the body with prominence in the frontal and occipital area, symmetrical in all places.

Normal

2. SCALP Inspection White, clean, free from masses, lumps, scars, and lesions, no areas of tenderness

White, slightly oily, without presence of masses, lumps, scars, and lesions but with presence of lice.

Improper hygiene..

3. FACE Inspection Oblong or round or square or heart shaped, symmetrical, facial expression that is dependent on the mood or true feelings and no involuntary muscle movements.

Oblong shaped, symmetrical with no involuntary muscle movements. No facial grimace is observed.

Normal

4. EYES Inspection Parallel and evenly spaced symmetrical, non-protruding, pink palpebral conjunctiva and pupils black in color, equal in size, round and constricts in response to light.

Parallel and evenly spaced, pupils are bluish gray in color, equal in size.

Normal

5. NOSE Inspection Midline symmetrical and patent, no discharge.

Midline symmetrical and patent, no discharge.

Normal

6. EARS Inspection Parallel symmetrical, proportional to the size of the head, bean-shaped, skin is same color as the surrounding color, clean firm cartilage.

Parallel symmetrical, proportional to the size of the head, bean-shaped, skin is same color as the surrounding color, clean firm cartilage. With presence of softened cerumen.There is also a presence of wound in the pina of the right ear of the client.

Improper hygiene.

7. MOUTH Inspection Symmetrical, gums pinkish in color, lips margin is symmetrical, no lesion and tenderness, without involuntary movement.

Symmetrical, gums pinkish to dark in color, lips is also dark brown in color..margin is symmetrical, no lesion and tenderness, .She have many dental cavities due to junk foods.

Improper dental care.

HEMATOLOGY:Date: July 21, 2009

Blood Components Results Normal Values

Hemoglobin 142 120-150 g/L- F

140-170 g/L- M

Hematocrit 0.44 0.37-0.47 g/L - F

0.40-0.50 g/L - M

Platelet Count 80 150-350 microliter

WBC 13,400 5,000-10,000 microliter

Time: 6 Am

The result of hematology examination has

a normal hemoglobin count as well as the

hematocrit. On the other hand the platelet or

the thrombocyte is way below the normal

value which indicates thrombocytopenia

while the leukocytes or the white blood cell

increase which shows that there’s an

infection present.

ANATOMY and PHYSIOLOGY:BLOOD

Blood- a connective tissuecomposed of a liquidextracellular matrix calledblood plasma that dissolvesand suspends various cells andcell fragments.

1 - Formed elements: • Red blood cells (or

erythrocytes) • White blood cells (or

leucocytes) • Platelets (or

thrombocytes) 2 - Plasma = water + dissolved

solutes

Characteristics of Blood:

• bright red

• dark red/purplish

• much more dense than pure water

• pH range from 7.35 to 7.45

• slightly warmer than body temperature

• typical volume in an adult is 5 liters

• 8% of body weight

Major Functions of Blood:

• Distribution & Transport

• Regulation (maintenance of homeostasis)

• Protection

Formed elements

RBC

• biconcave disk shape

• a hemoglobin carrier

• anucleate

• No mitochondria

• 120 lifespan

• erythropoietin is the hormone that stimulates RBC production

Erythropoiesis

RBC enters the circulation

Blood pass through the lungsAnd gas exchange occurs

Gas Exchange through tissues

RBC circulates for 120 days

WBC or Leukocytes:

• protection from microbes, parasites, toxins, cancer

• 1% of blood volume; 4-11,000 per cubic mm blood

• amoeboid motion • chemotaxis • leukocytosis

• leukopoiesis • Colony stimulating

Factors and interleukins-stimulates white blood cell formation

Types of White Blood Cells

Platelets

• formed in the bone marrow from cells called megakaryocytes

• very small, 2-4 microns in diameter

• approximately 250-500,000 per cubic millimeter

• essential for clotting of damaged vasculature

• Thrombopoietin stimulates the production

Platelet Plug Formation

platelets adhesion

damage to endothelium of vessel

platelets aggregation

Platelets release reaction

Pathophysiology Poor environmental sanitation

Mosquito bites a susceptible host

Virus multiply in the bloodstream

Creates multiple lesion in the blood stream

Increase capillary fragility

Excessive consumption of platelets

Increase vascular

permeability

Hemorrhagic manifestations

Thrombocytopenia Leakage of plasma

Pleural Effusion

Increased phagocytic activity

fever

Drug study

•Ranitidine

•Paracetamol

Medication Action Indication Contraindication Side Effects NursingResponsibilities

 Generic Name:Paracetamol

Brand Name:  

Dosage:

7-5 ml

Route:PO

 Decreases fever byinhibiting the

effects of pyrogenson the hypothalamic

heat regulatingcenters.

  Treatment of fever

and pain.

 Hypersensitivity • drowsiness• Nausea• Abdominal

pain• Anemia• vomiting

• Assess patients fever or pain:type of pain, location , intensity, duration, temperature, diaphoresis

• Assess allergic reactions:rash, urticaria, if these occur, drug may have to be discontinued.

• Check input and output ratio

• Inform th patient that urine may become dark brown as a result of phenacetin

• Teach patient to recognize signs of over dosage, bleeding, brising.

Medication Action Indication Contraindication Side Effects NursingResponsibilities

 Generic Name:Ranitidine

Brand Name:   Zantac

Dosage:

20 mg

Route:TIV

Frequency: q8

 Inhibits histamineat H2 receptor site

in the gastricparietal cells, whichinhibits gastric acid

secretion.

  Used inmanagement ofVariousGastrointestinaldisorders such as GIhemorrhage.

 Hypersensitivity.History of acuteporphyria

• Bradycardia• Headache• Fatigue• Dizzines• Insomnia• Depression

• Assess potential for interactions with other pharmaceutical agents patient may be taking.

• Use caution in presence of renal and hepatic impairment

• Do not take any new medication during therapy without consulting a physician

• Take axactly as directed

• Follow diet as physician recommends

• Report chest pain or irregular heartbeats, skin rash, CNS change; unusual persistent weakness or lethargy, yellowing of skin or eyes.

Nursing Care Plan

•Hyperthermia

•Impaired Skin Integrity

Cues Nursing diagnosis

Nursing objective

Planning Nursing intervention

Rationale Evaluation

Subjective Cues:

“Mainit padin po

ang pakiramdam

ko as verbalize by

the client.”

Objective Cues:

>Body temperature

of 38.6 degrees

celcius

>Hot, flushed skin.

>diaphoresis

>Increased

WBC(13,400 μL)

BP: 100/90 mmhg

PR: 78 bpm

Temperature: 38.6

degrees celcius

RR: 18bpm

Alterations in body

temperature related to

increase pyrogens

in the bloodstrea

m

ScientificExplanati

on:Body

temperature above normal range

After 3hours ofNursing

Intervention the clients

temperature will decrease into a normal range(36.5-37.5 degrees

celsius)

>Formulate

Independent

plans to meet

Your objective

in reducing

clients’

temperature

>Gather

Materials

needed in the

Implementation

of the nursing

interventions.

>Plan strategies

to educate

Significant others

so that they can

be

helpful in your

Nursing

Intervention.

>Perform TSB

Continuously

>Remove Excessive

Clothes and covers

>Promote

Increase Fluid

intake

>Maintain bed rest.

>Provide Proper

Ventilation

>Educate

Significant Others

Regarding Normal

Temperature and

Control measures

Promotes heat loss through conduction and evaporation.To promote surface cooling by evaporationPrevent dehydration.

To reduce metabolic demands To promote heat loss through convection.To reduce their anxiety and get their cooperation upon caring for the client.

After 3 hours of Nursing

Intervention the clients

temperature is decreased into a normal

range 37.3 degrees celsius

Cues Nursing diagnosis

Nursing objective

Planning Nursing interventi

on

Rationale Evaluation

Subjective Cues:

Objective Cues:

BP: 100/90 mmhg

PR: 78 bpm

Temperature: 38.6

degrees celcius

RR: 18 bpm

>Give

Antipyretics

Medication

As ordered

For immediate decrease in patients body temperature.

Cues Nursing diagnosis

Nursing objective Planning Nursing interventio

n

Rationale Evaluation

Subjective Cues:

“Makati po ang

mga sugat ko sa sa

braso at binti” as

verbalized by the client

Objective Cues:>presence of

wounds in the

lower right

extremity and both

forearm.

>pruritus

>warm to touch

wound surface.

>with watery

discharge.

Impaired skin integrity related to

mechanical factors as

evidence by disruption of skin surface

Scientific

Explanation

Alteration of the

Epidermis

because of

external factors

such as shearing

force

After 3 days of

Nursing

intervention

the client will be

able to display

improvement in

wound healing as

evidenced by:

•Intact skin or

minimized

presence of

wound..

•Absence of

Redness

orerythema.

•Absence of

Purulent

discharge.

•Absence of

itchiness.

>Plan intervention that will promote wound healing in a given span of time.>formulate ways on how to teach significant others in proper caring of the wounds.>Use methods to improve skin integrity in an accessible and easy way.

Assessed skin. Noted color, turgor, and sensation. Described and measured wounds and observed changes Demonstrated good skin hygiene, e.g., wash thoroughly and pat dry carefully.

Instructed family to maintain clean, dry clothes, preferably cotton fabric

(any T-shirt).

Establishes comparative baseline providing opportunity for timely

intervention.

Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin.Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection

After 3-days

of nursing

intervention,

the client was

able to

Display

Improvement

in wound

healing as

Evidenced

by:

•Minimized

presence of

wounds.

•Several

wounds have

dried up.

•Minimized

Erythema

•Minimized

itchiness

Cues Nursing diagnosis

Nursing objective

Planning

Nursing intervention

Rationale Evaluation

Subjective Cues:

Objective Cues:

BP: 100/90 mmhg

PR: 78 bpm

Temperature: 38.6

degrees celcius

RR: 18 bpm

Emphasized

importance of

Adequate nutrition

and fluid intake. Demonstrated

to the family

members on how to

make a guava

decoction to apply

to the wound as

Alternative

disinfectant.Instructed

family to clip and

file nails regularly.Provided and

applied wound

dressings carefully.

Improved nutrition and hydration will improve skin condition.

Providing the family with alternative solution assists them in optimal healing with less

expensive resources.

Long and rough nails increase risk of skin damage.

Wound dressings protect the wound and the surrounding tissues.

DISCHARGE PLAN:• Medicine – Paracetamol PRN.

-Don’t give aspirin and NSAIDs• Exercise- Encourage patients to resume to her Activities of daily living

-perform range of motions and repetitive body movements for promotion of optimum health.

• Therapy- Water Therapy-Promotion of proper personal hygiene.

• Health teachings- Change water in vases on alternate days. - cover water containers - used mosquito repellant lotions.. -avoid places with stagnant waters.

• Out patient follow up care- Instruct the family members to have a check-up after a week for detection of recurrences and other complications that may arise on to it.

• Diet- Instruct the family members to give the client protein rich foods such as meat, fish, eggs and nuts,

-Vitamin K rich foods such as green leafy vegetables

-Vit C rich foods(guava and tomatoes and other citrus fruits)

-Carbohydrates rich food (breads and rice)

• Spiritual- Encourage the patient to pray together with the family to thank God for her wellness. Ask for more guidance and protection to prevent the recurrence of the disease among family members.