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.