INTRODUCTIONDengue fever is caused by one of the four closely related, virus sero-types; Dengue type 1, Dengue 2, Dengue type 3 and Dengue type 4 of the genus flavivirus and chikinggunya virus. Infection with one of these serotype provide immunity to only that serotype life, to a person living in a dengue endemic area can have more than one dengue infection during their lifetime. Dengue fever through the four different dengue serotyped are maintain in the cycle which involves humans and aedes aegypti or aedes albodictus mosquito through the transmission of the viruses to humans by the bite of an infected mosquito. The mosquito become infected with the dengue when it bites a person who has dengue and after a week it can transmit the virus while biting a healthy person. Dengue cannot be spread from person to person. Aedes Aegypti is the most common Aedes Spices which is a domestic, Dax-biting mosquito that prefers to feed on humans.

INCUBATION PERIOD: Uncertain probably 6-10 days.PERIOD OF COMMUNICABILITY: Unknown presumed to be on 1st week of illness when virus still present in blood.

CLINICAL MANIFESTATION1ST 4 DAYS:-Febrile or Invasive Stabe: Starts abruptly as high fever, abdominal pain and headache ; later flusing which may be accompanied by vomiting , conjunctival infection and epistaxis.

4TH – 7TH DAY-Toxic or Hemorrhagic Stage: Lowering of temperature, severe abdominal pain , vomiting and frequent bleeding from GIT in the form of melena; unstable BP, narrow pulse pressure and shock, death may occur , vasomotor collapse.

7TH – 10TH DAY-Convalescent or recovery Stage: Generalize flushing with intervening areas of blanching appetite regained and blood pressure already stable.

CLASSIFICATION1. SEVERE , FRANK TYPE

-Flushing, sudden high fever, severe hemorrhage followed by sudden drop of temperature, shock and terminating recovery.

2. MODERATE -with high fever with less hemorrhage , no shock pressure.

3. MILD -with slight fever, with or without petichial hemorrhage but epidemiologically related

typicalcases usually discovered in the course of invest or typical cases.

GRADE 1:-FEVER-Non specific constitutional symptoms such as anorexia,and vomiting and abdominal pain.-Absence of spontaneous bleeding

GRADE 2-sign and symptoms of grade 1 ; pluv-presence of spontaneous bleeding ; muco cutaneousGRADE 3-sign and symptoms of grade 2 with more sever bleeding plus-evidence of circulatory failure; cold, dammy skin , irritability, wear to compressible pulses, narrowing of pulse pressure to 20mmhg or less, cold extremities, mental confusionGRADE 4-sign and symptoms of grade 3; declared shock , massive bleeding , pulse less and anterial blood pressure=1mmhg(dengue syndrome)

Medical ManagementBecause dengue fever is caused by a virus, there is no specific medicine or antibiotic to treat it. For typical dengue, the treatment is purely concerned with relief of the symptoms(symptomatic). Rest and fluid intake for adequate hydration is important. Aspirin and non steroidal anti-inflammatory drugs should only be taken under a doctor's supervision because of the possibility of worsening hemorrhagic complications .Acetaminophen (Tylenol) and codeine may be given for severe headache and for the joint and muscle pain (myalgia).

ManagementDo not give Aspirin because it contains at antiplatelet property which prmotes bleeding.Treatment is solely supportive and includes:* Fluids.* Analgesics (not aspirin) for fever and muscles aches.* Replacement of plasma or plasma expanders.

Nursing ManagementDengue is a self-limited illness but recovery might take afew weeks.

Independent:Close monitoring of vital signs in critical period (between days 2 to day 7of fever) is critical.Increased oral fluid intake is recommended to prevent dehydration.Treatment is purely concerned with relief of the symptoms (symptomatic).

Dependent:-Because dengue is caused by a virus, there is no specific medicine or antibiotic to treat it.-Aspirin and non steroidal anti-inflammatory drugs should be avoided as these drugs may worsen the bleeding tendency associated with some of these infections.-Acetaminophen (Tylenol) and codeine may be given for severe headache and for the joint and muscle pain (myalgia). -(DHF) Oxygen and sedatives may be administered.

Collaborative:A platelet transfusion is indicated in rare cases if the platelet level drops significantly (below 20,000) or if there are significant bleeding.The presence of melena or blood in the stool may indicate internal gastrointestinal bleeding requiring platelet and/or red blood cell transfusion

Theoretical Framework 

Florence Nightingale, often considered the first nurse theorist, defined nursing over 100 years ago as "the act of utilizing the environment of the patient to assist him in his recovery". She linked health with fiveenvironmental factors:•Pure or fresh air•Pure water•Efficient drainage•Cleanliness•Light, specially direct sunlight

Night ingale 's  environmental   factors  atta in  s ignificance  when oneconsiders  that  sanitat ion  condit ions   in  hospita ls  of   the mid-1800s weree x t r e m e l y   p o o r   a n d   t h a t   w o m e n   w o r k i n g   i n   t h e  h o s p i t a l s   w e r e   o f t e n unreliable, uneducated, and incompetent to care for the ill.In addition to those factors, Nightingale also stressed the importanceof  keeping  the c l ient  warm, mainta in ing a noise- free  environment,  andattending to the client's diet in terms of assessing intake, timeliness of thefood, and its effect on the person.N i g h t i n g a l e   s e t   t h e   s t a g e   f o r   f u r t h e r   w o r k   i n   t h e  d e v e l o p m e n t   o f   nursing theories. Her general concepts about ventilation, cleanliness, quiet,warmth, and diet remain integral parts of nursing and health care today.In the current setting of our client in Angono General Hospital, she wasclearly deprived of fresh air, pure water, and cleanliness. The OB/CS ward isnot  sui table   for  health  recovery  s ince  there are   foul  odors present . Poor ventilation deprives the client of fresh air. About cleanliness, environmental.

Biographical Data

Personal Data

Name: A. A

Age: 13

Address: Cogeovill, Antipolo

Birthday: Feb. 23,2000

Religion: R.C

Educational Background: Student

School Attainment: High School

Civil Status: single

Occupation: N/A

Date of Admission:

Time of admission:

Physician: Dra. Guevarra

Place of Admission: ANTIPOLO MEDICAL HOSPITAL

Admitting Diagnosis: DENGUE HEMORRHAGIC FEVER 2

HISTORY1 CHIEF COMPLAIN

•The patient complains of abdominal pain, headache, fever and general flushing of skin with on and off vomiting.

2 PRESENT ILLNESS•Four days prior to admission, the patient had an intermittent fever associated with abdominal pain, headache, and general flushing of theskin with on and off vomiting. A few hours prior to admission still the abovesign and symptoms remain but already have (-) vomiting withaccompanying chills and was diagnosed with Dengue hemorrhagic fever.

3 PAST MEDICAL YEARS•It was according to the patient that he wasn't been hospitalized yet not until when he was diagnosed with Dengue hemorrhagic fever. Before that diagnosis, he was already experiencing fever and his mom gives him a Paracetamol for remedy.

4 FAMILY HISTORY•A c c o r d i n g t o h i s g r a n d m o t h e r t h e o n l y d i s e a s e t h a t t h e f a m i l y h a s genetically is Diabetes Mellitus and no other diseases noted.

5 SOCIAL HISTORY•A.A is the son of Mr. and Mrs. SJ. •His father works as a seaman while his mother is a housewife; hisgrandmother is also living with them. Hence, his grandmother and his mother were the ones responsible in all the household chores.According to A.A, he eats vegetables and fish instead he preferseating hotdogs. Furthermore he has no other vices except for computer games. After school hours, he goes directly to the computer shop together with his brother and friends.

6 ENVIRONMENTAL HISTORY•According to the patient the environment that the family have has an opendrainage, wherein big rats and cockroaches can be seen. The house is cleaned by his mother and grandmother. It was described by the patient that there are parts of their house that is deprived from light.

C. HISTORY OF ILLNESS•During the mid of August, A.A, started experiencing fever that persist only at night. As a remedy his mom gave him Paracetamol to lower his body temperature. Except from fever he’s also experiencing abdominal pain,headache and general flushing of the skin with on and off vomiting.As the above signs and symptoms persists, his parent decided to bring him to the hospital.Upon the physical assessment and after several diagnostic proceduresthat the patient had undergone, he was diagnosed with Dengue Hemorrhagic Fever (DHF) and was admitted under the service of Dra. Guevarra.

Anatomy and PhysiologyThe Circulatory System

The circulatory system in humans is a network of blood vessels through which the heart pumps the blood and keeps the blood in circulation.

The circulatory system provides blood to each cell in the body. Comprises of two sub systems:

1. Cardiovascular system -- consists of the heart, blood and the blood vessels in the form of arteries and veins.

2. Lymphatic system --consists of the lymph vessels, lymphatic nodes and lymph. 3. When the blood reaches the intestines, it collects nutrients for distribution and discards the

waste collected from the body cells to the intestines. 4. The blood carries the oxygen and the nutrients to the tissues of the body where it exchanges

them with carbon dioxide and waste from the cells.5. Waste like toxins are released into the kidneys.6. Another important role of blood is to carry the white blood platelets that have the capacity to

fight germs and contain diseases to the infection areas. Therefore, blood helps the immune system of the bodyThe Heart

The heart is a special involuntary muscle called the cardiac muscle. Involuntary muscles keep working on their own without our intervention or effort. The heart is divided into two sides divided by the septum. Each side has two chambers: A. a ventricle and B. an atrium. The left side of the heart is responsible for pumping the oxygenated blood from the lungs to the

rest of the body. The right side of the heart is responsible for bringing the deoxygenated blood back to the lungs.

Blood VesselsThe cardiovascular system part of the circulatory system is a closed network of blood vessels through which the blood keeps circulating due to the action of the heart.There are two categories of blood vessels:

Arteries - carry the oxygenated blood from the heart to the rest of the body where it distributes the oxygen and nutrients, The largest arteries called the aorta

veins - carry the deoxygenated blood from the body organs back to the heart. The largest vein called the vena cava are each about an inch in diameter!

Lymph When the blood carries the nutrition to the individual cells and collects waste, it forms the

interstitial fluid between the cells of a tissue to transfer the nutrients to the cells. The lymphatic system is a network of one way vessels that collect the interstitial fluid called

lymph into the lymph vessels which push the lymph by rhythmic contractions through several lymph nodes on the way into the subclavian veins where the lymph mixes back with the blood.

Blood is composed of a fluid called plasma that contains red blood cells, white blood cells and

platelets. The plasma carries the proteins, hormones and minerals from one part of the body to the

other. Red blood cells contain hemoglobin which helps transport oxygen from the lungs to the rest of

the body parts. The white blood cells help to fight infections and diseases. The blood platelets help to clot after an injury thereby preventing an excess loss of blood

Important functions of blood within the body including: Supply of oxygen to tissues (bound to hemoglobin which is carried in red cells) Supply of nutrients such as glucose, amino acids, and fatty acids (dissolved in the blood or bound

to plasma proteins) Removal of waste such as carbon dioxide, urea, and lactic acid

Immunological functions, including circulation of white blood cells, and detection of foreign material by antibodies

Coagulation, which is one part of the body's self-repair mechanism Messenger functions, including the transport of hormones and the signalling of tissue

damage Regulation of body pH (the normal pH of blood is in the range of 7.35 - 7.45) Regulation of core body temperature

PLASMAPlasma is a pale yellow fluid that accounts for over half of the total blood volume. Itconsists of 92% water and 8% suspended or dissolved substances such as proteins, ions,nutrients, gases, waste products, and regulatory substances.Plasma volume remains relatively constant. Normally, water intake through the GITclosely matches water loss through the kidneys, lungs, GIT and skin. The suspended anddissolved substances come from the liver, kidneys, intestines, endocrine glands, and immunetissues as spleen.

PREVENTING BLOOD LOSS

When a blood vessel is damaged, blood can leak into other tissues and interfere with thenormal tissue function or blood can be lost from the body. Small amounts of blood from the bodycan be tolerated but new blood must be produced to replace the loss blood. If large amounts of  blood are lost, death can occur.

BLOOD CLOTTINGPlatelet plugs alone are not sufficient to close large tears or cults in blood vessels. When a blood vessel is severely damaged, blood clotting or coagulation results in the formation of a clot.A clot is a network of threadlike protein fibers called fibrin, which traps blood cells, platelets andfluids.The formation of a b lood c lot depends on a number of proteins found with in p lasma called clotting factors. Normally the clotting factors are inactive and do not cause clotting.Following injury however, the clotting factors are activated to produce a clot. This is a complex process involving chemical reactions, but it can be summarized in 3 main stages; the chemicalreactions can be stated in two ways: just as with platelets, the contact of inactive clotting factorswith exposed connective tissue can result in their activation. Chemicals released from injuredtissues can also cause activation of clotting factors. After the initial clotting factors are activated,they in turn activate other clotting factors. A series of reactions results in which each clottingfactor activates the next clotting factor in the series until the clotting factor prothrombin activator is   formed.  Prothrombin  act ivator  acts  on an  inact ive  c lott ing  factor  ca l led  prothrombin.Prothrombin is converted to its active form called thrombin. Thrombin converts the inactiveclotting factor fibrinogen into its active form, fibrin. The fibrin threads form a network whichtraps blood cells and platelets and forms the clots.

CONTROL OF CLOT FORMATIONWithout control, clotting would spread from the point of its initiation throughout thee n t i r e   c i r c u l a t o r y   s y s t e m .   T o   p r e v e n t   u n w a n t e d   c l o t t i n g ,  t h e   b l o o d   c o n t a i n s   s e v e r a l anticoagulants which prevent clotting factors from forming clots. Normally there are enoughanticoagulants in the blood to prevent clot formation. At the injury site, however, the stimulationfor activating clotting factors is very strong. So many clotting factors are activated that theanticoagulants no longer can prevent a clot from forming.

CLOT RETRACTION AND DISSOLUTIONAfter a c lot has formed, i t begins to condense into a denser compact structure by a  process known as clot retraction. Serum, which is plasma without its clotting factors, is squeezedout of the clot during clot retraction. Consolidation of the clot pulls the edges of the damagedvessels together, helping the stop of the flow of blood, reducing the probability of infection andenhancing healing.

PATHOPHYSIOLOGY

PREDISPOSING FACTOR:-school -age-barangay

PRECIPITATING FACTOR:-environmental sanitation-mosquito carrying dengue virus-sweat skin

Aedes Aegypti ( dengue virus carrier) 8-12days of viral replication on mosquitos salivary gland.

Bite from mosquito (portal of entry)Early sign: -redness and itchiness in the area

Dengue virus mix in the blood circulation (incubation period: 3-14 days)SIGN AND SYMPTOMS:-frebile: 38.6-diaphoresis, warm skin, flushed:loss of appetie; body weakness.

Virus disseminated rapidly into the blood and stimulates WBC including B lymphocytes that produces and secretes immunoglobulins (antibodies) , and monocyte/ macrophages, neutrophils as evidence by the laboratory results:HEMATOLOGY:-decreased WBC.3.7 (4.5-11)-increase lymphocyte: 0.58%(25-33)

Virus disseminated rapidly into the blood and stimulates WBC including B lymphocytes that produces and secretes immunoglobulins (antibodies) , and monocyte/ macrophages, neutrophils as evidence by the laboratory results:HEMATOLOGY:-decreased WBC.3.7 (4.5-11)-increase lymphocyte: 0.58%(25-33)

Antibodies attach to the viral antigens, and then monocytes macrophages will perform phagocytosis through Fc reception within the cells and dengue virus replicates in the cells of monocytes or macrophages.IF NOT PREVENTED:-enter to the spleen and liver.-enter to the bone marrow that can lead to death.

Recognition of dengue viral antigen on infection monocyte by acytotoxics cells.

Release of cytokines which consist of avaso active agents such as inteleukins, tumors necrosis factor, urokinase and platelet activating factor which stimulates WBC and pyrogen release.

DENGUE FEVER

NURSING CARE PLANASSESMENT DIAGNOSIS PLANNING INTERVENTIONS EVALUATIONSUBJECTIVE:(dumudugo ang gums ng anak ko kapag kumakaen sya ng kornik sa bahay) as verbalize by the mother.

OBJECTIVE:-weakness and irritability-restlessnes

RISK FOR BLEEDING

After 1hr. of nursing interventions, the client will be able to demonstrate behaviors that reduces risk for bleeding.

INDEPENDENT:-asses for any signs of bleeding.-check for fecal color.-observe for presence of petechiae, ecchymosis, and bleeding for one more sites.-monitor pulse and blood preassure.-note change of mental consciousness.-avoid rectal temperature, be gentle with G.I tube insertion.-Ecouraged use of soft toothbrush, avoiding straining for stool, and forceful nose

After 1hr. of nursing interventions, the client was able to demonstrate behaviors that reduces risk for bleeding.

blowing.-monitor Hb,platelet count ,hct, and clotting factor.

DRUG STUDY

DRUG NAME CLASSIFICATION ACTION INDICATION CONTRAINDICATION ADVERSE EFFECT

NURSING RESPONSIBILITIES

Genericname:Paracetamol

Brandname:Biogesic

Dose:500 mg 1 tabRoute:OralFrequency:q 4

Analgesic ( Non-opioid)Antipyretic

Paracetamol maycause analgesia byinhibiting CNSprostaglandinsynthesis. Themechanism of morphine isbelieved to involvedecreasedpermeability of thecell membrane tosodium, whichresults indiminishedtransmission of pain impulsestherefore analgesia.

To relieve mildto moderatepain due tothings such asheadache,muscle and joint pain,backache andperiod pains. Itis also used tobring down ahigh temperature.For this reason,paracetamolcan be givento children after vaccinations to preventpost-immunizationpyrexia (hightemperature).Paracetamol isoften includedin

Hypersensitivity toacetaminophen orphenacetin; use withalcohol

Hematologic:hemolyticanemia,leukopenia,neutropenia,pancytopenia,thrombocytopenia.Hepatic:liver damage, jaundiceMetabolic: hypoglycemiaSkin:rash,urticuria

>Assess patient’s feveror pain: type of pain,location, intensity,duration, temperature,and diaphoresis.>Assess allergicreactions: rash,urticaria; if these occur,drug may have to bediscontinued.>Teach patient torecognize signs of chronic overdose:bleeding,

cough, coldand flu

bruising,malaise, fever, sorethroat.>Tell patient to notifyprescriber for pain/fever lasting for morethan 3 days.

DRUG NAME CLASSIFICATION ACTION INDICATION CONTRAINDICATION ADVERSE EFFECT

NURSING RESPONSIBILITIES

Famotidine Histamine 2 (H2) antagonist

Competitively blocks the action of histamine at the histamine (H2) receptors of the parietal cells of the stomach; inhibits basal gastric acid secretion and chemically induced gastric acid secretion.

Short-term treatment and maintenance of duodenal ulcer

Short-term treatment of benign gastric ulcer

Treatment of pathologic hypersecretory conditions

Short-term treatment of gastroesophageal reflux disease (GERD), esophagitis due to GERD

Relief of symptoms of heartburn, acid indigestion, sour stomach (OTC)

Allergy to famotidine; renal failure; pregnancy; lactation.

Headache, malaise, dizziness, somnolence, insomnia, Rash, Diarrhea, constipation, anorexia, abdominal pain, Muscle cramp, increase in total bilirubin, sexual impotence

Administer drug at bedtime.

Decrease doses with renal failure.

Arrange for administration of concurrent antacid therapy to relieve pain.

DRUG NAME CLASSIFICATIONS

ACTIONS INDICATION CONTRAINDICATION ADVERSE EFFECT

NURSING RESPONSIBILITY

ISOPRINOSINE

Antivirals >Synthetic antiviral: it stimulates T-

Rhinovirus; herpes genitalis;

>Hypersensitivity. Patients w/ adnormally low

>Transient increase in urine and

>Monitor increase in serum uric

lymphocytes; used for HIV and Hepatitis

>non-toxic immune system stimulant

measles; encephalitis; influenza; herpes zoster; herpessimplex; type A & B hepatitis; AIDS related complex; neoplastic diseases; anergy andhypoergy prior to major surgery

neutrophil counts (< 0.75 x 10x9/L), or abnormally low haemoglobin levels (< 7.5 g/dL or 4.65 mmol/L)

serum uric acid level; very rarely skin rashes; pruritis;GI upset; nausea; fatigue; malaise

acid level, gout, urolithiasis or renal dysfunction; pregnancy and lactation>Monitor hematological parameters

LABORATORY EXAMINATIONSHEMATOLOGY REPORT

PARAMETER NORMAL FINDINGS ACTUAL FINDINGS ANALYSISWBC 5 – 10 X 10̂ g/L 3.9 x 10 ̂ g/L Decrease due to

inadequate inflammatory defenses to suppress infection and humoral immunity takes place

HEMOGLOBIN M: 13.0 -18.0 g/ L 10.2 g/L Decrease due to poor oxygen supply

HEMATOCRIT 39-54 % 31 % Decrease due to poor oxygen supply

SEGMENTERS 0.60- 0.70 0.73 Increase ; indicate high

glucose level in the bloodLYMPHOCYTES 0.20-0.30 0.27 NormalPLATELET COUNT 150-450 x 10^g/L 145 x 10 ^g/L Decrease platelet count

FECALYSIS REPORT

PARAMETERS NORMAL FINDINGS ACTUAL FINDINGS ANALYSISPhysical Properties COLOR YELLOW BROWN Due to the presence of

bacteria

LABORATORY EXAMINATIONS HEMATOLOGY REPORT

PARAMETERS NORMAL FINDINGS ACTUAL FINDINGS ANALYSISWBC 5 – 10 X 10̂ g/L 5 – 10 X 10̂ g/L NORMALHEMOGLOBIN M: 13.0 -18.0 g/ L 10 g/dl Decrease due to poor

oxygen supplyHEMATOCRIT 39-54 % 30 % Decrease due to poor

oxygen supplySEGMENTERS 0.60- 0.70 0.68 NORMALLYMPHOCYTES 0.20-0.30 0.58 Increase due to the body’s

increased immune systemPLATELET COUNT 150-450 x 10^g/L 85 x 10^g/dl Hemolysis

Discharge Planning

Medications:> Give acetaminophen in case the temperatures increases .> Give oresol to replace fluid in the body.

>Remind to take the prescribed medicine, having a written reminder of the correct medication,time to take, and the right frequency of the medicine on the way home to establish assurance of medication compliance.

Exercise : >Instruct to avoid excessive activities that may result to stress.>Just advised to perform range of motions and repetitive body movements for promotion of optimum

Treatment: Currently, no medications are available to treat dengue hemorrhagic fever.  > Increased oral fluid intake. >Admission to an intensive care unit>Intravenous fluids and electrolytes >Oxygen therapy > Transfusions of blood and platelets as needed> Bed rest

Health Teaching: ( for prenvention) > D- discuss the possible source of infection of the disease. > E- educate the family/patient on how to eliminate those vectors .> N- Never stocked water in a container without cover .> G- Gallon, container and tires must have proper way of disposal. > U- Use insecticides at home to kill or reduce mosquito.

Out-Patient Follow-Up Care : >Instruct the family members to have a check-up or to consult physician once a while to monitor

patient’s condition and for detection of recurrences and other complications that may arise on to it.

Diet: > Encourage nutritious foods like vegetables, meat and fruits.> Instruct the family members to give the client protein rich foods such as meat, fish, eggs andnuts, vitamin K rich foods such as green leafy vegetables, vit C rich foods(guava and tomatoesand other citrus fruits), carbohydrates rich food (breads and rice)