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DENGUE

HEMORRAGHIC

FEVER

A Case Study Presented

Siena College Taytay, Rizal

In Partial Fulfillment of the Requirements

For the degree - Bachelor of Science in Nursing

Karlo G. Bartolome

September 24, 2010



Introduction

NTRODUCTION

Dengue Fever is caused by one of the four closely related, but antigenically

distinct, virus serotypes Dengue type 1, Dengue type 2, Dengue type 3, and

Dengue type 4 of the genus Flavivirus and Chikungunya virus. Infection with one

of these serotype provides immunity to only that serotype of 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 serotypes are maintained

in the cycle which involves humans and Aedes aegypti or Aedes albopictus

mosquito through the transmission of the viruses to humans by the bite of an

infected mosquito. The mosquito becomes infected with the Dengue virus 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 transmitted or directly spread from

person to person. Aedes aegypti is the most common aedes specie which is a

domestic, day-biting mosquito that prefers to feed on humans.

INTUBATION PERIOD:Uncertain. Probably 6 days to 10 days

PERIOD OF COMMUNICABILITY: Unknown. Presumed to be on the 1st week

of illness when

virus is still present in the blood

CLINICAL MANIFESTATIONS:

MODE OF TRANSMISSION:

Dengue viruses are transmitted to humans through the infective bites of

female Aedes mosquito. Mosquitoes generally acquire virus while feeding on the

blood of an infected person. After virus incubation of 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.

Humans are the main amplifying host of the virus. The virus circulates in

the blood of infected humans for two to seven days, at approximately the same



time as they have fever. Aedes mosquito may have acquired the virus when they

fed on an individual during this period. Dengue cannot be transmitted through

person to person mode.

CLASSIFICATION:

1. Severe, frank type

>flushing, sudden high fever, severe hemorrhage, followed by sudden drop of

temperature, shock and terminating in recovery or death

2. Moderate

>with high fever but less hemorrhage, no shock present

3. Mild

>with slight fever, with or without petichial hemorrhage but epidemiologically

related to typical cases usually discovered in the course of invest or typical cas

Dengue haemorrhagic 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.

Last June 16, 2008, I encountered a patient with such kind of infection. This

patient has caught my attention and has given the opportunity to study his case.

The objective of this study is to help me understand the disease process of Dengue

Fever and to orient myself for appropriate nursing interventions that I could offer to the patient. This approach enables me to exercise my duties as student nurse

which is to render care. I was given the chance to improve the quality of care I can

offer and to pursue my chosen profession as future nurse.

I humble myself to present my studied case and submit myself for further

corrections to

widen the scope of my knowledge and understanding.



Objectives

Objectives of this case study were based on 11 competency standards of nursing practice.

General Objectives

• This case study aims to develop the application of critical and analytical thinking in the

nursing practice.

Specific Objectives

• To practice safe and quality nursing care by formulating Nursing Care Plans

• To give health education by performing health teaching with the patient and his family

• To practice legal and ethico-moral responsibility by documenting care rendered to the

patient

• For personal and professional development.

• Promotion of quality nursing service.

• To apply research findings in nursing practice

• To improve record management by maintaining accurate and updated documentation of

patient care

• To practice therapeutic communication with the client.

• To establish collaborative relationship with colleagues and other members of the health

team for the health plan



Significance of the study

To Nursing Students, It will help develop analytical and critical thinking by understand the

disease through anatomy and pathophysiology, analyzing the proper care to the patient by

formulating nursing care plans, drug study and recording the condition of the client by physical

examination, patient’s profile and activities in daily living.

To Nursing Educators, it will aid in identifying vital competencies to be developed in nursing

students, particularly proficiency of roles and functions in patient care and supervision.

To Hospital Management, It will contribute in improving quality of care to the patients by

applying nursing interventions mentioned in the case study.

To the Readers, It will serve as a guide in understanding more about peptic ulcer and its proper

nursing ,medical and collaborative management.

Scope and delimitations

The study was conducted in medical Ward of Rizal Provincial Hospital last September

24, 2010. The study focused on patient with Dengue Hemorrhagic fever. The topics to be

discussed are: Introduction, Theoretical Framework, Pathophysiology, Anatomy & Physiology,

and Patient’s History, Physical Assessment, Hematology, Drug study, Discharge Plan and the

Nursing Care Plan. All subjects discussed, nursing interventions and recorded data were limited

and based on the patient’s condition.



Theoretical Framework

14 Functions of Nursing Care

By

Virginia Henderson

(1897 – 1996)

Virginia Henderson graduated from the Army School of Nursing, Washington, D.C., in

1921.Virginia Henderson defined nursing as "assisting individuals to gain independence in

relation to the performance of activities contributing to health or its recovery". Her famous

definition of nursing was one of the first statements clearly delineating nursing from

medicine:"The unique function of the nurse is to assist the individual, sick or well, in the

performance of those activities contributing to health or its recovery (or to peaceful death) that

he would perform unaided if he had the necessary strength, will or knowledge and to do this in

such a way as to help him gain independence as rapidly as possible" (Henderson, 1966). She was

one of the first nurses to point out that nursing does not consist of merely following physician's

orders. Henderson enumerated the 14 functions she believed to be part of basic nursing care. The

nurse should help the patient to perform the following functions:

The 14 components

• Breathe normally.

• Eat and drink adequately.

• Eliminate body wastes.

• Move and maintain desirable postures.

• Sleep and rest.

•

Select suitable clothes-dress and undress.• Maintain body temperature within normal range by adjusting clothing and modifying

environment

• Keep the body clean and well groomed and protect the integument

• Avoid dangers in the environment and avoid injuring others.

• Communicate with others in expressing emotions, needs, fears, or opinions.



• Worship according to one’s faith.

• Work in such a way that there is a sense of accomplishment.

• Play or participate in various forms of recreation.

• Learn, discover, or satisfy the curiosity that leads to normal development and health and

use the available health facilities.

HUMAN

Breathe normally.

Eliminate body

wastes.

Move and maintain

desirable postures.

Sleep and rest

Select suitable

clothes-dress and

undress

Maintain body

temperature within

normal range

Keep the body well

groomed and protect

the integument

Eat and drink

adequately.

Learn, discover, or

satisfy the curiosity

that leads to normal

development

Play or participate in

various forms of

recreation

Work in such a waythat there is a sense

of accomplishment

Worship according to

one’s faith

Communicate with

others in expressing

emotions, needs,

fears, or opinions

Avoid dangers in the

environment and

avoid injuring others



Synthesis

Virginia Henderson’s theory is very applicable to this case study. The patient was

admitted in the surgery ward for a very long time and in order to give holistic care to the patient

the nurse must consider the 14 functions of nursing care.

• The patient must breathe normally which means the nurse must monitor the client’s

respiratory rate. It should be in the normal rate of 12-20 breaths per minute.

• The patient must eat and drink adequately. The nurse must consider that the patient is

diabetic and hypertensive so it means the nurse should only allow foods that have low

glucose (carbohydrates), sodium and encourage nutritious food for the patient. The

patient is also encouraged to eat egg white because it is rich in albumin and the patient is

experiencing hypoalbuminemia.

• In elimination of body waste the nurse must monitor the output of the patient if it is

normal. The patient must have urine output of 30ml/hour and defecate at least once a day.

• The nurse must also move and maintain posture of the patient comfortably.

• The nurse must ensure that the patient is have an adequate sleeping and resting time

while in the hospital.

• The nurse must know if the patient is comfortable in his clothing in the hospital.

• The nurse must monitor the patient’s temperature. An elevation of temperature may

indicate infection.

• The nurse must give the patient proper skin care specially the client is diabetic and got a

punctured wound which means the healing is slower.

• The nurse must ensure the patient is safe from injuries while in the ward by securing the

bed rails etc.

• The nurse must practice therapeutic communication with the patient. The patient might

be experiencing anxiety due to prolong stay in the hospital.

• The nurse must not also give physiological care but also spiritual care to the patient and

respect the belief or faith of the patient.



• The nurse must provide recreational activities during the patients stay in the ward like

reading.

PHYSICAL ASSESSMENT

The patient was assessed last September 3, 2010.

BODY PART METHODS

USED

NORMAL

FINDINGS

ACTUAL

FINDINGS

ANALYSIS

HEAD

HAIR Inspection Black evenly

distributed andcovers the whole

scalp, thick,

shiny. Free fromsplit ends.

Presence of

white hairs andunevenly

distributed.

Changes in hair

color typicallyoccur naturally as

people age,

eventually turningthe hair gray and

then white

(melanin production ceases).

This is called

achromotrichia.

FACE Inspection Oblong or oval

square or heartshape,

symmetrical

facial expression

that is dependenton the mood or

true feelings,

smooth and freefrom wrinkles, no

involuntary

muscle movement

Oblong shape,

facialexpression

looks tired and

discomfort,

and

Because of

irritation

TEETH Inspection 32 permanent

teeth, wellaligned, free from

caries or filling,

no halitosis.

32 permanent

complete

normal



THORAX &

LUNGS

Breathing Inspection Normal

Respiratory rate:12-20 breaths per

minute

Respiratory

rate of 18 breaths per

minute.

Respiratory rate is

the number of breaths patient

takes within acertain amount of time (frequently

given in breaths

per minute).

Average normalrespiratory rates

for adults are 12-

20 breaths per minute.

Heart rate Auscultation Normal Heart

rate: 60-100 beats per minute

Heart rate of

72 beats per minute.

No noticeable

alterations in the patient’s heart rate.

Blood Pressure Auscultation Normal blood

pressure: 120/80

120/80 normal

ABDOMEN Inspection,

Palpation,

Auscultation, &Percussion

Skin is

unblemished,

color is uniform,flat rounded,

symmetrical

movement cause

by respiration

Skin is a little

dry, color is

uniform, flatrounded,

symmetrical

movement

cause byrespiration

Skin is slightly dry

because skin loses

moisture andelasticity

EXTREMITIES

Palms and

dorsal surface

Inspection &

Palpation

Palm pinkish and

warm

Pinkish, warm

and a littlehard

Palms are hard

because of the patient’s nature of

work.

Legs Inspection/

palpation

Tan, skin is

smooth hair

evenly distributedabsence of

varicose veins

Both legs are

equally

movable

Because of trauma



Pathophysiology



DRUG

NAME

ACTION INDICATIO

N

CRONTRAINDICATI

ON

SIDE

EFFECT

NURSING

CONSIDERATI

ONRanitidine

Hydrochloride

Brand:

Zantac

Dosage:

50 mg I.V

Classificatio

n:

Gastrointestin

al drug (Anti-

ulcer drug

Competitivel

yinhibits

action

of histamine

onthe H2

receptor

sites of

parietal

cells,

decreasinggastric acid

secretion

Active

duodenaland gastric

ulcer

Used to

prevent ulcer while patient

is

on NPO

Contraindicated

in patientshypersensitive

to drug and

those with with

acute porphyria

Use cautiously

in patients with

hepatic

dysfunction.

Adjust dosagein patients

withimpairedren

EENT:

Blurred visionHepatic:

jaundice

Other:

burning anditching at

injection

site,

anaphylaxis,a

ngioe

dema

Assess

patient for abdominal

pain. Note

presence of

emesis, stool, or gastric .aspirate

• Proper used

of OTC

preparation

as indicated.

• Take once daily prescription drug

at bed time for

best results

• Instruct

patient to

take without

regard to

meals because

absorption

isn’t affected

by food.



DRUG NAME ACTION INDICATION CRONTRAINDICA

TION

SIDE EFFECT NURSING

CONSIDERATION

GENERIC NAME:

Omeprazole

BRAND NAME:Losec (CAN)

DRUG

CLASSIFICATION:

Antisecretory drug

Proton pump inhibit

DOSAGE: 40g

FREQUENCY: OD

ROUTE: IVTT

Gastric

acid-pump

inhibitor:Suppresse

s gastric

acid

secretion

by specific

inhibition

of the

hydrogen-

potassium

ATPase

enzyme

system atthe

secretorysurface of

the gastric

parietal

cells;

blocks the

final step

of acid

productio

Indicated for:

y Short-term

treatment of activeduodenal

ulcer;

First-line therapy

in

treatment of

heartburn or

symptoms of

gastroesophageal

reflux

disease (GERD);

y Short-term

treatment of active benign

gastric ulcer;yGERD, severe

erosive

esophagitis, poorly

responsive

symptomatic

GERD;

y Long-term

therapy:

Treatment of

pathologichypersecretory

conditions

(Zollinger-Ellison

syndrome, multiple

adenomas,

systemic

mastocytosis);

y Eradication of H. pylori

with amoxicillin or

metronidazole and

clarithromycin

Contraindicated with

hypersensitivity to

omeprazole or itscomponents;

Use cautiously with

pregnancy,

lactation.

CNS:

Headache,

dizziness,asthenia,

vertigo,

insomnia,

apathy, anxiety,

paresthesias,

dream

abnormalities

Dermatologic:

Rash,

inflammation,

urticaria,

pruritus,alopecia, dry

skinGI: Diarrhea,

abdominal

pain, nausea,

vomiting,

constipation,

dry mouth,

tongue atrophy

Respiratory:

URI symptoms,

cough, epistaxisOther: Cancer

in

preclinical

studies,

back pain, fev

C: Antisecretory

drug;

Proton pumpinhibitor

H: IVTT

E: decrease gastric

acid

secretion

C: Take the drug

before

meals.

Report severe

headache,

worsening of

symptoms, fever,chills.

K: Swallow thecapsules whole; do

not

chew, open, or

crush

the



PATIENT’S PROFILE

Name: Mr X

Age: 21

Gender: male

Address: 14 dalig st. Teresa, Rizal

Date of Birth: September 9, 1987

Place of Birth: Muntinlupa City

Nationality: Filipino

Religion: Roman Catholic

Civil Status: Single

Date of Admission:

Time of admission:

Physician:

Place of Admission: Rizal Provincial Hospital

Admitting Diagnosis: Dengue Fever Syndrome

HISTORY OF PRESENT ILLNESS

The patient is a 21 year-old male, a grade three student who was diagnosed with Dengue Hemorrhagic

Fever II. Five days prior to admission the client suffers from having a high fever with a temperature of39.

4 degrees celcius, Paracetamol was given for relief. After three days the fever subsidesandabdominal pain

and vomiting of brownish colored vomitus takes place.Due to persistence of the saidsigns and symptoms,

the patient seek consultation and hence admitted at Rizal Provincial Hospital Dr. San Jose as her

attending physician.

Upon admission the child has experienced gum bleeding with presence of petechiae over theface and

lower extremities accompanied by loss of appetite. Hematology examination shows lowplatelet count

with a value of 100 mm3.During the interview session she has a fever and experiences no gum bleeding at

all. Herabdominal pain becomes intermittent.

PAST MEDICAL HISTORY

According to the patient’s mother, she experienced having urinary tract infection when she wasfive years

old. The patient only experiences having common cough and colds occasionally. She alsoexperiences

fever before and it was relieved by over the counter drugs and rest. Their family does notseek

consultation for regular health check up. She has not been hospitalized and only seeks consultationto their

Baranggay Health Center whenever any health problem arises. She did not receive animmunization

vaccine for measles. She also denies having allergies to food and drugs. She says that sheis allergic to

dust and particles



LABORATORY FINDINGS:

RESULT NORMAL FINDINGS ANALYSIS

Hemoglobin

Hematocrit

Segmenters

Lymphocytes

Platelet count

10.2 g/dL

31 %

0.73

0.27

100 x 10^g/dL

F: 13.0-18.0 g/dL

39-54 %

0.60-0.70

0.20-0.30

150-450 x 10^g/

Increased due to

presence of infectionDecreased due to

bleeding or

hemorrhage

Decreased due to

bleeding or

hemorrhage

Increased due to high

glucose level in the

blood

l

Due to presence of bleeding



DISCHARGE TEACHING

Medication

Remindto 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.

Don’t give aspirin and NSAID’s, they increase the risk of bleeding. Any medicines that decrease

platelet count should be avoided.

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

Health Teaching.

Remind about the need for health promotion activities such as reading, watching T.V, etc.

Treatment

Bed rest is advisable during the re-occurrence of fever phase.

Instruct to drink plenty of water or fluids that are available at home and eat nutritious diet.

Advised to look for re-occurrence of danger signs and symptoms and report immediately.

Hygiene

Encourage to continue the routinely hygienic care of the patient

Out-Patient Follow-Up Care

Instruct the family members to have a check-up or to consult physician once a while to

monitorpatient’s condition and for detection of recurrences and other complications that mayarise on to it

DIET

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



ASESSMENT DIAGNOSIS ANALYSIS INTERVENTION RATIONALE EVALUATIO

Subjective:

“Masakitang

tiyanko” asverbalized by

the patient.

Objective:

>C pain scale

of

7/10>grimace

noted

>irritable>weakness

noted

Characteristic:Stabbing,

shooting pain

Onset:

“pasumpongsumpongpo

eh”

as verbalized by

patient

Location:

No exactLocation” sa

buongtiyanpohas

verbalization

Duration: 2-3

minutesExacerbations:

Gets worst

when pressure is

applied in th

Acute pain

related to

inflammatoryresponse as

evidenced byverbalizationof patient “

masakitpo

tiyanko” pain

scale of 7/10,grimace &

irritabilit

This is due to

Entry of

pathogensin circulation

leading torelease of anti-

inflammatory

mediators and

as avascular

response it

cause increasein

capillary

permeabilityleading to

hyperemia and

cellular

exudation,swelling and pai

Independent:

>monitor v/s

>Instructed to

deep breathingexcersise

>Encourage to

have Diversional

activities likewatching t.v.

>Place patient ina comfortable

position

>Encourage to

have adequate

bed rest

>Provided

therapeutic touch

Dependent:

>Administered

Ranitidine as

ordered

> To determine

alteration in present

condition

>Helps relieving

pain

>To divertattention

from and reduce

pain felt

>To provide

comfort

>To have energy

> Helps in

relieving pain

Goal Partially

met,

After 30 hourof nursing car

the patientwas able toreduced pain

felt from 7/10

to 5/10 as

evidencedverbalization

of the patient



GORDON’S 11 FUNCTIONAL HEALTTH PATTERN

HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

Before hospitalization:

The patient perceived his health in the state of good condition. He perceives health as

wealth and he values his health a lot. He manages his health by practicing proper hygiene and

eating nutritious food.

During hospitalization:

He sees himself as a total ill person because he cannot do anymore the things he usually

does like playing with his siblings. He rely his present condition with the help of the therapeutic

personnel and by following the prescribed medications. The patient perceived that he is not

healthy because of his condition.

NUTRITIONAL-METABOLIC PATTERNBefore hospitalization:

The patient eats 3 times a day and with afternoon snacks after coming from school.

According to the SO of the patient, he eats meat, fish and also vegetables. He doesn’t have any

allergies on foods and drugs. His appetite is moderate and usually depends on the food being

served. He didn’t complain any difficulty in swallowing.


The patient has loss his appetite and hasn’t eaten a lot. He is on a DAT (Diet asTolerated) EDCF (Except Dark Colored Foods).

ELIMINATION PATTERN


The patient does not have any problem on his elimination pattern. He usually urinates 4-

5 times a day without any difficulty. He added that the color of his urine is light yellow. He

didn’t feel any pain in urination. The patient defecates once a day usually early in the morning

before going to school with yellow to brown color. He verbalized that sometimes however, it is

hard in consistency with dark color, which generally depends on what he eats.


The patient urinates 2-3 times a day. The color of her urine is yellow. The patientdefecates once every two days.

ACTIVITY-EXERCISE PATTERN

Before hospitalization:He could perform activities of his daily living. According to him, he often plays

with his siblings and this serves as a form of exercise for him.




His activity was limited lying on bed but the patient is given his bathroom

privileges.

SLEEP-REST PATTERN


He has the normal 6-8 hours sleep. He also has his nap time for 1-2 hours a day.

Sleeping and watching the television are his form of rest.During hospitalization:

He doesn’t have the adequate time of sleep since he is disturbed with the nurses that

enter the room every now and then, and because of the environmental changes of his

surroundings. He also has inadequate time to rest since he doesn’t have enough time to sleep.

COGNITIVE-PERCEPTUAL PATTERN


He is normal in terms of his cognitive abilities. He has good memory and reasoning

skills. He can easily comprehend on things. In terms of his perceptual pattern, he has no

problems with his senses.


He was normal as before in his cognitive and perceptual pattern. He responds clearly and

well understood. He has no sensory deficit; He responds appropriately to verbal and physical

stimuli and obeys simple commands.

SELF-PERCEPTION – SELF-CONCEPT PATTERN

He sees himself as a person with a good personality. He has been a good friend, brother

and a son. He said he has to be a good person in order not to hurt others. He also describes

himself as a typical type of student and person.

ROLE-RELATIONSHIP PATTERN


He has a close relationship with his family. They were five siblings in their family. He

was at the middle. I was also able to ask his mother about his being a son and she confessed thathe is a good son but at times he doesn’t obey her. He is also a responsible student and knows all

his duties as a friend.




He had more time to bond with his family. He said that it was a nice feeling to know that

your family is so supportive to him. He learned to appreciate the beauty of having a family that

gives you strength and support no matter what.

SEXUALITY-REPRODUCTIVE PATTERN

According to him, he doesn’t think of the things like having a girlfriend and gettingmarried yet. He is still young for such matters.

COPING-STRESS TOLERANCE PATTERN


He does not fully identify his situations having stress but he always tell her parents when something is wrong.


He shares his problems to his family. He verbalizes his feelings.VALUE-BELIEF PATTERN

He is a Roman Catholic devotee. He always goes with his family every Sunday to

go to mass. He was taught by his family to believe and have fear to GOD. They usually believe

in quack doctors.

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