Our Lady of Fatima University College of Nursing Regalado, Quezon City

A Case Study on Dengue Fever

In Partial Fulfillment of the Requirements in Nursing Care Management 102A Related Learning Experience

Presented by: BSN 2Y2-4 Group 21

Gianchand, Olivia P. Manuel, Janine M.

Second Semester S.Y 2011-2012

I. Introduction Dengue Fever is an infectious disease carried by mosquitoes and caused by any 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. This disease used to be called break-bone fever because it sometimes causes severe joint and muscle pain that feels like bones are breaking, hence the name, there may also be gastritis associated to abdominal pain, nausea, vomiting, or diarrhea. Infection with one of this 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. Dengue cannot be transmitted or directly spread from person to person. It can be transmitted by Aedes Aegypti mosquito to humans usually attacking during the day and shortly after the rainy season in tropical and subtropical areas of Africa, Southeast Asia and China, India, Middle East, Caribbean and Central and South America, Australia and the South and Central Pacific. After virus incubation for eight to 10 days, an infected mosquito is capable, during probing and blood feeding, of transmitting the virus for the rest of its life. Infected female mosquitoes may also transmit the virus to their offspring by transovarial (via the eggs) transmission, but the role of this in sustaining transmission of the virus to humans has not yet been defined. The incidence of dengue has grown dramatically around the world in recent decades. Some 2.5 billion people, two fifths of the world's population, are now at risk from dengue. WHO currently estimates there may be 50 million dengue infections worldwide every year. There is no specific treatment for dengue fever. Health experts have known about dengue fever for more than 200 years.

II. Objectives

General:

This study aims to identify and determine the general health problems and needs of the patient with an admitting diagnosis of Dengue Fever. It also intends to help patient promote health and medical understanding of such condition through the application of the nursing skills.

Specific:

1.) To raise the level of awareness of patient on health problems that she may encounter. 2.) To facilitate patient in taking necessary actions to solve and prevent the identified problems on her own. 3.) To help patient in motivating her to continue the health care provided by the health workers. 4.) To render nursing care and information to patient through the application of the nursing skills.

III. Patients Profile A. Biographical Data 1. Name: 2. Address: 3. Age: 4. Birthdate: 5. Sex: 6. Race: 7. Marital status: 8. Occupation: 9. Religion: Ms. C.T. Barangay 309,Sampaloc, Manila 10 June 19,2001 Female Filipino Single N/A Catholic

10. Health Care financing and usual source of Medical Care: Supported by the patients parents

A. Working Diagnosis Dengue Fever Syndrome

B. Chief Complaint and Reason for Visit: Fever

C. Past Medical History: Our patient was never admitted to the hospital. Until she was diagnosed with dengue fever syndrome. Before Ms. C.T. was diagnosed to have dengue, she had fever and was given Paracetamol by her mother at home.

D. Family History of Illness: The patient has a family history of hypertension. According to her, both of her parents have hypertension.

E. History of Present Illness:

Four days prior to admission, the patient had on and off fever. She would usually have fever in the afternoon. As a remedy, the patients mother gave Paracetamol to reduce her body temperature. Aside from fever, Ms. C.T. also experienced abdominal pain, headache, general flushing of the skin and vomiting. As the signs and symptoms persisted, her mother decided to bring her to the hospital. After the physical assessment and diagnostic tests, Ms. C.T. was diagnosed to have Dengue Fever Syndrome by the attending physician.

IV. Physical Assessment Assessment Body Build, Height & Weight Posture And Gait Body And Breath Odor Signs Of Distress Attitude Affect Or Mood Normal Findings Proportionate Varies With Lifestyle Stands normally No Body Or Breath Odor No Distress Noted Cooperative Appropriate To The Situation Understandable, Moderate Pace, Thought Association Logical Sequence Make Sense, Has Sense Of Reality Actual Findings Proportionate Varies With Lifestyle Stands normally No Body Or Breath Odor distress noted Cooperative Appropriate To The Situation Understandable, Moderate Pace, Thought Association Logical Sequence Make Sense, Has Sense Of Reality Interpretation Proportionate body there is no evidence of physical problems Relaxed, erect posture; coordinated movement Proper hygiene maintenance Because of lack of sleep, distress noted Thinks normally, proper to the situation She acts and think normally appropriate to the situation Can speak normally, with normal voice tone

Quantity, Quality And Organization Of Speech Relevance And Association Thought Exhibits

Talking with sense means she thinking normally

Skin Assessment Uniformity Of Skin Color Normal Findings Uniformity Except In Areas Expose To The Sun Actual Findings Uniformity Except In Areas Expose To The Sun Interpretation Uniformity of skin, except areas expose to light and some areas of lighter pigmentation(conjunctiv as, palms, lips, nail beds) No water retention No lesion noted in the body

Edema Skin Lesion

No Presence Of Edema Freckles, some birthmarks, some flat and raised nevi; no abraisions or other lesions Moisture In Skin Folds & Axillae Uniform, Within Normal Range Skin Springs Back To Previous State When Pinched

No Presence Of Edema No reckles, some birthmarks, some flat and raised nevi; no abraisions or other lesions Moisture In Skin Folds & Axillae Uniform, slightly above normal range Skin Springs Back To Previous State When Pinched, except the part with edema

Skin Moisture

Skin Temperature Skin Turgor

Some body parts that having sebaceous glands are moisture Low grade fever Skin stays pinched or tented or moves back slowly

Skull and Face Assessment Head Normal Findings Rounded And Symmetrical, Smooth Skull Contour, No Nodules Light to deep brown, smooth and symmetric facial movement Actual findings Rounded And Symmetrical, Smooth Skull Contour, No Nodules Pinkish, smooth and symmetric facial movement Interpretation Normal, no signs of any deformities and signs of skull contour and nodules

Face

Fever causes flushing of the skin

Eyes and Vision Eyebrows Evenly Distributed, Symmetrical, Skin Intact Skin Intact, No Discharges, No Discoloration, Symmetrical Equally Distributed, Slightly Curved Outward Shiny, Smooth ,Sometimes Appear Red Or Pink No Edema Or Tearing Transparent, Shiny, Smooth, Blinks When Cornea Is Touched Black Color, smooth border, PERRLA Can see without using eyeglasses Evenly Distributed, Symmetrical, Skin Intact Skin Intact, No Discharges, No Discoloration, Symmetrical Equally Distributed, Slightly Curved Outward Properly distributed, equal

Eyelids

Can blink normally

Eyelashes

Turned outward, equally distributed, muscle normally contract

Conjunctiva

Pale conjunctiva

Pale, possible anemia

Lacrimal Gland Cornea

No Edema Or Tearing Transparent, Shiny, Smooth, Blinks When Cornea Is Touched Black Color, smooth border, PERRLA Cant see without eyeglasses

Pupils

Normal no evidence of any swelling or tenderness Corneal sensitivity test active, trigeminal nerve is intact, cornea clarity and texture normal. Pupils are equal, constrict to light dilate in the dark Nearsightedness, can see only when objects are near

Eyes(Visual Acuity)

Ears and Hearing Auricles Color Is Uniform, Symmetric, Mobile, Firm pinna Recoils When Folded Normal Voice Tone Audible Color Is Uniform, Symmetric, Mobile, Firm pinna Recoils When Folded Cannot hear Normal Voice Tone Color same as facial skin, auricle aligned with outer canthus of the eye. Abnormal cannot hear Normal voice, normal voice tones

Response To Normal Voice Tone

Nose and Sinuses Nares Symmetric, Straight, No Discharges, Non Swelling, Uniform Color, Not Tender Nasal Septum In Midline Symmetric, Straight, No Discharges, Non Swelling, Uniform Color, Not Tender Nasal Septum In Midline No presence of lesions,air moves freely as the client breaths

Lining Of Nose

Normal and in midline

Mouth Lips And Buccal Mucosa Teeth And Gums Pink, Soft, Symmetrical,moist Complete Pink, Soft, Symmetrical,dry Complete Due to fever which causes dehydration No tooth decay,smooth shiny tooth enamel,no dentures In Central position,moist,slightly rough ;thin whitish coating,normal,can move freely No discoloration, palates are lighter pink hard palate

Tongue

In Midline, Freely Movable, Pink

In Midline, Freely Movable, Pink

Palates And Uvula, Tonsils

Light Pink, No Discharges, Present Gag Reflex

Light Pink, No Discharges, Present Gag Reflex

Shape And Symmetry Spinal Deformities Inspect Neck Muscles

Neck and Musculoskeletal System Symmetrical Symmetrical Vertically Aligned Symmetrical With Head Centered Vertically Aligned Symmetrical With Head Centered

Positioned in midline Normal, no deformities No swelling or masses, coordinated, smooth movements with no discomfort No discomfort, can hyper extends, laterally flexes and rotates

Observe Head Movement

Muscle

Coordinated, Smooth, Movement With No Discomfort, Equal Strength Size Is Symmetrical, No Contracture, Normally Firm

Coordinated, Smooth, Movement With No Discomfort, Equal Strength Size Is Symmetrical, No Contracture, Normally Firm

Equal strength, symmetrical, normal

Bones

No Deformities, No Swelling Or Tenderness No Swelling, No Tenderness Varies To Some Degrees

No Deformities, No Swelling Or Tenderness No Swelling, No Tenderness Limited range of motion in one or more joints

Normal, can move freely, no swelling, deformities or tenderness Normal, no signs of swelling in area, no tenderness Can stand and walk, but limited range of motions due to muscular pain brought by the condition

Joints

Range Of Motion

V. Activities of Daily Living Functional Health Pattern Health Perception and Health Management Before her present condition Perceives herself as a strong healthy child. Reports to mother when she feels sick Visits the health center for check-up when sick. During her present condition Thinks that she is weak and not healthy Complies with medications Interpretation The patient had changed her perception about her health because of the signs and symptoms brought by the disease

Nutritional and Metabolic

Eats 3 times daily. The usual food intake would be composed of meat vegetables Drinks 5 glasses of water per day and drinks juice in school

Same amount of food is taken. Avoids eating dark colored food

Dark colored food was avoided to easily detect blood in stool Fluid intake was increased due to replace fluid loss. Juice and other acidic food were eliminated to avoid irritation to gastric mucosa

Drinks 8 glasses of water. Juice is eliminated in her diet

Elimination

Moves bowel once a day without difficulty

Same bowel movement frequency

Soft firm stool Same urine Voids fair amount of urine elimination frequency without difficulty in normal frequency Same amount and quality of feces and Clear, yellow urine urine

The condition did not affect her elimination pattern

Activity Exercise

Her usual routine was to go to school in the morning and watch television after doing her homework. Also helps in household chores

Sleep-Rest

Has 8 hours of sleep everyday Deep, uninterrupted sleep

Doesnt go to school anymore. Cant do any household chores. Spends time by talking to her mother and playing games in her mothers cellphone Has maximum of 7 hours of interrupted sleep

Her usual activity was affected because she feels weak due to her condition.

Takes nap in the Gets enough energy from afternoon to sleep compensate lost Doesnt need any sleep aids sleeping hours CognitivePerceptual Normal hearing acuity and does not use hearing aid Normal hearing acuity and does not use hearing aid

Inadequate sleep due to noisy environment and interrupted sleep due to compliance to the medication

Uses eyeglasses Uses eyeglasses Able to comprehend easily Able to comprehend easily Feels that she may get lower grades in school because of being absent. She is concerned of not being able to attend her choir rehearsals.

The patients condition has no effect on cognition and perception

Self-Perception and Self-Concept Pattern

Perceives herself as a good daughter and student. She shows interest in music.

Being confined in the hospital made her unable to go to school and do rehearsals

VI. Development Tasks

Industry vs. Inferiority At the age of ten, the significant task of the patient is being aware of themselves as individuals. People at this age work hard at being responsible, being good and doing things right. Ms. C.T. is starting to recognize her special talents and continue to discover interests as her education improves. During the assessment, she had verbalized that she is worried of getting low grades since she cant listen to class discussion anymore. She also mentioned that there is a choir competition that she should have attended if she were not in the hospital. It is obvious that the patient is able to perform her task as a school age child. This will surely help her in building self-confidence which is important to possess as she grows older.

VII. Laboratory/Diagnostic Findings CBC and Platelet Count Norms 115-155 0.40-0.48 5.0-10.0 0.2-0.4 0.6-0.7 150-450 Result 116 0.41 12.8 0.08 0.63 110 Analysis normal normal Due to infection Due to viral infection normal Due to infection

Hemoglobin Hematocrit WBC Count Lymphocytes Segmenters Platelets

Torniquet test 10 petichiae per square inch Interpretation: Positive for Dengue fever syndrome

VIII. Anatomy and Physiology BLOOD Blood is a specialized bodily fluid that delivers necessary substances to the body's cells such as nutrients and oxygen and transports waste products away from those same cells. It is composed of blood cells suspended in a liquid called blood plasma. Plasma, which comprises 55% of blood fluid, is mostly water (90% by volume), and contains dissolved proteins, glucose, mineral ions, hormones, carbon dioxide (plasma being the main medium for excretory product transportation), platelets and blood cells themselves. The blood cells present in blood are mainly red blood cells (also called RBCs or erythrocytes) and white blood cells, including leukocytes and platelets. The most abundant cells in vertebrate blood are red blood cells. These contain hemoglobin, an iron-containing protein, which facilitates transportation of oxygen by reversibly binding to this respiratory gas and greatly increasing its solubility in blood. In contrast, carbon dioxide is almost entirely transported extracellularly dissolved in plasma as bicarbonate ion. Blood is bright-red when its hemoglobin is oxygenated. It is circulated around the body through blood vessels by the pumping action of the heart. Blood performs many important functions 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 signaling of tissue damage, regulation of body pH (the normal pH of blood is in the range of 7.35 - 7.45) (covering only 0.1 pH unit), regulation of core body temperature Blood accounts for 7% of the human body weight, with an average density of approximately 1060 kg/m3, very close to pure water's density of 1000 kg/m3. The average adult has a blood volume of roughly 5 liters, composed of plasma and several kinds of cells (occasionally called corpuscles); these formed elements of the blood are erythrocytes (red blood cells), leukocytes (white blood cells), and thrombocytes (platelets). By volume, the red blood

cells constitute about 45% of whole blood, the plasma constitutes about 54.3%, and white cells constitute 0.7%. Whole blood (plasma and cells) exhibits non-Newtonian fluid dynamics; its flow properties are adapted to flow effectively through tiny capillary blood vessels with less resistance than plasma by itself. In addition, if all human hemoglobin were free in the plasma rather than being contained in RBCs, the circulatory fluid would be too viscous for the cardiovascular system to function effectively.

PLATELETS Platelets, or thrombocytes, are small, irregularly-shaped anuclear cells, 2-4 m in diameter, which are derived from fragmentation of precursor megakaryocytes. The average lifespan of a platelet is between 8 and 12 days. Platelets play a fundamental role in hemostasis and are a natural source of growth factors. They circulate in the blood of mammals and are involved in hemostasis, leading to the formation of blood clots. If the number of platelets is too low, excessive bleeding can occur. However, if the number of platelets is too high, blood clots can form (thrombosis), which may obstruct blood vessels and result in a stroke and/or a heart attack. An abnormality or disease of the platelets is called a thrombocytopathy, which could be either a low number of platelets (thrombocytopenia), a decrease in function (thrombasthenia), or an increase in the number of (thrombocytosis). There are disorders that reduce the number of platelets, such as heparin-induced thrombocytopenia (HIT) or thrombotic thrombocytopenic purpura (TTP) that typically causes thromboses, or clots, instead of bleeding. A thrombus or blood clot is the final product of blood coagulation, through the aggregation of platelets and the activation of the humoral coagulation system. Thrombus is physiologic in cases of injury, but pathologic in case of thrombosis. Some of the conditions in which blood clots develop include atrial fibrillation (a form of cardiac arrhythmia), heart valve replacement, a recent heart attack, extended periods of inactivity (see deep venous thrombosis), and genetic or disease related deficiencies in the blood's clot. Platelet - High and low counts. A normal platelet count in a healthy person is between 150 and 400 (x 109/L of blood). Both thrombocytopenia (or thrombopenia) and thrombocytosis may present with coagulation problems

IX. Pathophysiology
Bite of aedes aegypti mosquito carrying a virus

Virus is deposited in the skin then into the circulation

Infects cells and generate cellular response

Initiates destruction of the platelet

Increased potential for hemorrhage

Stimulates intense inflammatory response

Release of exogenous pyrogens

body releases anti inflammatory mediators (histatin,kinins)

WBC (Neutrophils & Macrophages) Vascular response Release of endogenous pyrogens Redness and heat Reset of hypothalamic thermostat Headache, , Epistaxis, Vomiting Fever Muscle contract to produce more heat Blood vessels constrict to prevent loss of body heat Shock Abdominal pain, Circulatory collapse

SHIVERING

CHILLS

DEATH

X. Nursing Care Plan ASSESSMENT Subjective: "Limang araw ng nilalagnat ang anak ko," as verbalized by client's mother. DIAGNOSIS Hyperthermia related to Infection as evidenced by increased body temperature of 38.0 C PLANNING Short Term Goal: After 1 hour of nursing intervention, client will maintain normal core temperature of 36.5-37.5. INTERVENTION Independent y Promote surface cooling by y means of tepid sponge bath. To decrease temperature by means through evaporation and conduction. To support circulating volume and tissue perfusion. To reduce metabolic demands and oxygen consumption. RATIONALE EVALUATION Short Term Goal: After 1 hour of nursing intervention, client maintained a core temperature of 36.5 - 37.5.

Administer replacement fluids and electrolytes.

Objective: Flushed skin Warm to touch Restlesness

Maintain bed rest.

y Vital Signs: Temp: 38.0 C RR: 38 bpm

Remove excess clothing or blankets. Provide air condition/fan if appropriate.

Dependent y Administer antipyretics per physician's order. y To facilitate fast recovery.

XI. Drug Study DRUG NAME Acetaminophen Paracetamol CLASSIFICATION Analgesic, muscle relaxant, uricosurics ACTION Decreases fever by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilation. Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not haves antiinflammatory action because of its minimal effect of peripheral prostaglandin synthesis. INDICATION Relief of mild to moderate pain, treatment of fever. CONTRAINDICATION Hypersensitivity: Intolerance to tartrazine, alcohol, table sugar, saccharin. SIDE EFFECTS Stimulation, drowsiness, nausea, vomiting, abdominal pain, hepatoxicity, hepatic seizure, renal failure, leucopenia, neutropenia, hemolytic anemia, thrombocytopeni a, pancytopenia, rash, urticaria, hypersensitivity, cyanosis, anemia, jaundice, pancytopenia, CNS stimulation, delirium followed by vascular collapse, convulsion, coma and death. NURSING RESPONSIBILITIES Tell the patient to read the label on other OTC drugs. Advise patient to avoid taking more than one product containing paracetamol (Acetaminophen) at one time; as this may cause toxicity if taken concurrently. Advise patient to avoid alcohol; acute poisoning with liver damage may result; acute toxicity includes symptoms of nausea, vomiting and abdominal pain. Physician should be notified immediately.

Brand Name: Tylenol

XII. Discharge Planning y MEDICATION y Give acetaminophen in case the temperatures increases. Give oresol to replace fluid in the body.

EXERCISE TREATMENT

y y

Perform activities of daily living(ADLs) as tolerated Enough rest

y y y y

Increased oral fluid intake. 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. E - encourage the family of the patient to clean the surroundings to destroy the breeding places of mosquito Observe carefully for symptoms Give instruction about what symptoms to watch for so she can alert clinician if additional symptoms occur between visits Follow-up check ups Encourage nutritious foods like vegetables, meat and fruits.

HEALTH TEACHING

y y y

OPD FOLLOW-UP

y y y

DIET

How does Dengue affect the Body?

Dengue infection is caused by 1 of 4 related, but antigenically distinct, viral serotypes: dengue virus 1 (DENV-1), dengue virus 2 (DENV-2), dengue virus 3 (DENV-3), and dengue virus 4 (DENV-4). Albert Sabin speciated these in 1944. Each serotype is known to have several different genotypes. Dengue viruses are small, spherical, single-stranded enveloped RNA viruses of the family Flaviviridae, genus Flavivirus. Infection with one dengue serotype confers lifelong homotypic immunity and a very brief period of partial heterotypic immunity, but each individual can eventually be infected by all 4 serotypes. Several serotypes can be in circulation during an epidemic. Dengue viruses are transmitted by the bite of an infected Aedes mosquito. Globally, a aegypti is the predominant highly efficient mosquito vector for dengue infection, but A albopictus and other Aedes species can also transmit dengue with varying degrees of efficiency. Aedes mosquito species have adapted well to human habitation, often breeding around dwellings in small amounts of stagnant water found in old tires or other small containers discarded by humans. Female Aedes mosquitoes are daytime feeders. They inflict an innocuous bite and are easily disturbed during a blood meal, causing them to move on to finish a meal on another individual, making them efficient vectors. Entire families who develop infection within a 24- to 36-hour period, presumably from the bites of a single infected vector, is not unusual. Humans serve as the primary reservoir for dengue; however, certain nonhuman primates in Africa and Asia also serve as hosts. Mosquitoes acquire the virus when they feed on a carrier of the virus. The mosquito can transmit dengue if it immediately bites another host. In addition, transmission occurs after 8-12 days of viral replication in the mosquitos salivary glands (extrinsic incubation period). The mosquito remains infected for the remainder of its 15- to 65day lifespan. Vertical transmission of dengue virus in mosquitoes has been documented. The eggs of Aedes mosquitoes withstand long periods of desiccation, reportedly as long as 1 year, but are killed by temperatures of less than 10C. Once inoculated into a human host, dengue has an incubation period of 3-14 days (average 4-7 d). Following incubation, a 5- to 7-day acute febrile illness ensues. Recovery is usually complete by 7-10 days. DHF or DSS usually develops around the third to seventh day of illness, approximately at the time of defervescence. The major pathophysiological abnormalities that occur in DHF and DSS are plasma leakage and bleeding. Plasma leakage is caused by increased capillary permeability and may be manifested by hemoconcentration, as well as pleural

effusion and ascites. Bleeding is caused by capillary fragility and thrombocytopenia and may present various ways, ranging from petechial skin hemorrhages to life-threatening gastrointestinal bleeding. Most patients who develop DHF or DSS have had prior infection with one or more dengue serotypes. In individuals with low levels of neutralizing antibodies, nonneutralizing antibodies to one dengue serotype, when bound by macrophage and monocyte Fc receptors, have been proposed to result in increased viral entry and replication, and increased cytokine production and complement activation. This phenomenon is called antibody-dependent enhancement. In addition, certain dengue strains, particularly those of DEN-2, have been proposed to be more virulent, in part because more epidemics of DHF have been associated with DEN-2 than with the other serotypes.

Classification of Dengue Hemorrhagic Fever

Grade I There is fever accompanied by non-specific constitutional symptoms and the only hemorrhagic manifestation is positive tourniquet test Grade II All signs of Grade I plus bleeding from the nose, gums, GIT are present. Grade III There is presence of circulatory failure as manifested by weak pulse, narrow pulse pressure, hypotension, cold clammy skin and restlessness

Grade IV There is profound shock, undetectable blood pressure, and pulse.