DENGUE HAEMORRAGIC FEVER ( DHF )

GROUP 13

A4

Dengue haemorrhagic fever (DHF) is a disease caused by dengue virus is classified as a type of virus arbovirus and entered into the body through the bite of aedes aegypty (Christantie Efendy, 1995).

1. Definition

Dengue Haemorragic Fever is caused by the Arbovirus (arthro podborn virus) and Aedes transmitted by mosquitoes (Aedes albopictus and Aedes Aegepty)

2. Etiology

3. Risk FactorLiving in or traveling to Southeast Asia, South and Central America, Sub-Saharan Africa, and parts of the Caribbean can increase your risk of contracting the dengue virus. These patients are also at higher risk:•Age (fatal cases are among children and young adult).•Those with compromised immune systems•The elderly

Two main pathophysiological changes occur in DHF. One is an increase vascular permeability that gives rise to loss of plasma from the vascular com- partment. This results in haemoconcentration, low pulse pressure and other signs of shock, if plasma loss becomes critical. The second change is a dis-order in haemostasis involving vascular changes, thrombocytopenia and coagu-lopathy.

A constant finding in DHF/DSS is activation of the complement system, with profound depression of C3 and C5 levels. The mediators that increase vascular permeability and the precise mechanism(s) of the bleeding pheno-mena seen in dengue infections have not yet been identified; consequently,further studies are needed. Immune complexes have been described in DHF but their role is not yet clear. Platelet defects may be both qualitative and quantitative, i.e. some circulat-ing platelets during the acute phase of DHF may be exhausted (incapable of normal function). Therefore, even a patient with a platelet count greater than100000 per mm3 may still have a prolonged bleeding time.

4. Phatophysiological Concept

A mechanism that may contribute to the development of DHF/DSS is enhancement of virus replication in macrophages by heterotypic antibodies in secondary infections with a virus of a different serotype from that causing the primary infection, cross-reactive antibodies that fail to neutralize virus may increase the number of infected monocytes as dengue virus–antibody com-plexes are taken into these cells. This in turn may result in the activation of cross-reactive CD41 and CD81 cytotoxic lymphocytes. The rapid release of cytokines caused by the activation of T cells and by the lysis of infectedmonocytes mediated by cytotoxic lymphocytes may result in the plasma leakage and haemorrhage that occur in DHF.

N E X T

Dengue Hemorragic fever has signs and symptoms in the form of heat which lasts between 4-7 days after the bite of a mosquito carrying the virus is accompanied by the following symptoms which include:

•High heat up to more than 38 º C, which lasts up to 5-7 days.

•Headache and pain diretro-orbital (behind the eye).•Pain in muscles and joints.•Nausea and vomiting, no appetite.•The presence of digestive disorders (constipation or

diarrhea).•Abdominal pain.•The presence of rash (signs of redness) of the skin.

5. Clinical Manifestation

• Complete blood = Hemoconcentration ( Hematocrit and Hemoglobin increased by 20 % or more )• Thrombocitopeni ( 100 . 000 / mm3 or less ) • Leucosite decreased • Serology test = HI ( hemaaglutinaion Inhibition Test )• Pleural effusion Chest X = Thorax• Tourniquet Test (+)

6. Diagnostic Test

The diagnosis of dengue is usually made clinically. The classic picture is high fever with no localizing source of infection, a rash with thrombocytopenia and relative leukopenia - low platelet and white blood cell count. Fever, headaches, eye pain, severe dizziness and loss of appetite.Hemorragic tendency (positive torniquet test, spontaneous bruising, bleeding from mucosa, gingiva, injection sites, etc.; vomiting blood, or bloody diarrhea )Thrombocytopenia (<100,000 platelets per mm³ or estimated as less than 3 platelets per high power field)Evidence of plasma leakage (hematocrit more than 20% higher than expected, or drop in hematocrit of 20% or more from baseline following IV fluid, pleural effusion, ascites , hypoproteinemia)Dengue shock syndrome is defined as dengue hemorrhagic fever plus: Weak rapid pulse, Narrow pulse pressure (less than 20 mm Hg)and also Cold, clammy skin and restlessness.

7. Diagnosis

a. Tell patients to drink plenty of fluids and get plenty of rest. b. Tell patients to take antipyretics to control their temperature. c. Warn patients to avoid aspirin and other nonsteroidal, anti-

inflammatory medications because they increase the risk of hemorrhage.

d. Monitor patients hydration status. Educate patients and parents about the signs of dehydration and have them monitor their urine output.

e. If patients cannot tolerate fluids orally, they may need IV fluids. Assess hemodynamic status frequently by checking the patient’s heart rate, capillary refill, pulse pressure, blood pressure, and urine output

8. Therapeutic Management

f. Perform hemodynamic assessments, baseline hematocrit testing, and platelet counts.

g. A platelet transfusion may be indicated if the platelet level drops significantly (below 20,000) or if there is significant bleeding.

h. Keep patient in screened sickroom or under a mosquito net.

N E X T

Extensive BleedingShockEncephalopathyLiver damageResidual brain damageGlomerulonephritisVery low blood pressureEffuse pleuraImpairment of consciousness.

9. Complication

Significant morbidity and mortality can result if early recognition and monitoring of severe forms are not done. If left untreated, themortality of DHF patients may be as high as 40-50%. Early recognition of illness, careful monitoring and appropriate fluid therapy alone have decreased mortality to 1%. If shock is identified when pulse pressure starts to drop and intravenous fluids are administered, the outcome will be excellent. Recovery is fast and most patients recover in 24-48 hours without any sequelae. The outcome may not be so good if the patient develops cold extremities. Most deaths from DHF is caused by prolonged shock,massive bleeding, fluid overload and acute liver failure with encephalopathy. Severe refractory shock, DIC, ARDS, liver failure and neurological manifestations singly or in combination were the commonest causes of death in a recent series.The case fatality rate is high with shortage of experienced medical teams.

10. Prognosis

[ a ] Personal protection against mosquito biting : Screening doors and windowsProtective clothing, wear long pants and long sleeves. Application of mosquito repellents on exposed skin use mosquito repellant sprays that contain DEET when visiting places where dengue is endemic.Fogging

11. Prevention

[ b ] The best preventive measure is vector control methods : 1. Biological control

Largely experimental Option: place fish in containers to eat larvae

2. Environmental control

Elimination of larval habitats; Cover water holding containers, Discard artificial containers..

3. Chemical control Larvicides may be used to kill immature aquatic stages Ultra-low volume fumigation is ineffective against adult mosquitoes as Aedes aegypti is fully domesticatedMosquitoes may have resistance to commercial aerosol sprays

a. Review the basic data, the need for bio-psycho-social-spiritual patients from various sources (patients, families, medical records and other health team members).

b. Identify potential sources and available to meet patient needs.c. Review the history of nursing.d. Assess the increase in body temperature, signs of bleeding,

nausea, vomiting, no appetite, sore muscles and joints, signs of shock (rapid and weak pulse, hypotension, cold and moist skin .

1. Assesment

1. Hyperthermia related to the process of dengue virus infection.

2. Fluid volume deficit related to active fluid loss.3. The risk of bleeding related to decreased blood clotting

factors (thrombocytopenia).4. The risk of disruption nutritional needs less than body

requirements related to inadequate nutrient intake due to nausea and decreased appetite.

5. Activity Intolerance related to weak body condition.6. Deficient Knowledge: about the disease process related

toa lack of information.

2. Nursing Diagnosis

1 . Hyperthermia associated with the process of dengue virus infection.Goal : Normal body temperatureOutcome Criteria : Body temperature between 36-370Ca.Observations intake and output, vital signs (temperature, pulse, blood pressure) b.Give warm compressesc. Provide / encourage patients to drink plenty of 1500-2000 cc / day (as tolerated)d.Instruct the patient to wear thin and easily absorbs sweate.Collaboration: intravenous fluid and drug delivery according to the program.

3. Nursing Plan

2 . Fluid volume deficit associated with active fluid loss.Goal: Do not occur volume fluid deficit.Outcome Criteria : - Input and output balance. - Vital signs within normal limits. - There is no sign of pre-shock. - Akral warm. - Capilarry refill less than 3 seconds.Intervention: a. Monitor vital signsb. Observation of capillary refill.c. Observations intake and output. Note the color of urine /

concentration, specific gravity.d. Suggest to drink 1500-2000 ml / day (as tolerated)Collaboration: intravenous fluid.

Implementing phase, provide the actual nursing activities and client responses. Implementation consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions or nursing orders.

4. Implementation

Normal body temperature Do not occur volume fluid deficit. There was no bleeding No disruption nutritional needs Activities of daily needs are metKnowledge about DHF can be

understand by patient / family

5. Evaluation

Thank You !!