OBJECTIVES

General objective
This case study aims to identify and determine the general health problems and needs of
the patient with an admitting diagnosis of dengue hemorrhagic fever. This presentation
also intends to help patient promote health and medical understanding of such condition
through the application of nursing skills. This paper is also intended to provide a better
understanding of the disease process based on the patients health history and as a
reference for future nursing students.

Specific Objectives

To raise the level of awareness of patient and family on health problems

that they may encounter

To facilitate the patient and family in taking necessary actions to solve and
prevent the identified problems on her own

To trace the disease process as well as possible etiologies.

To render nursing care and information to patient through the application

of the nursing skills.

To create a nursing care plan for individualized care of the patient.

ANATOMY AND PHYSIOLOGY

BLOOD
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients
and oxygen to the cells and transports metabolic waste products away from those same cells.

PHYSICAL CHARACTERISTIC
Bright red (oxygenated) dark red/purplish (unoxygenated). Much more dense than pure
water. pH range from 7.35 to 7.45 (slightly alkaline). Slightly warmer than body
temperature 38.Celsius. Typical volume in adult male 5-6 liters typical volume in adult
female 4-5 liters typically 8% of body weight
COMPONENTS OF BLOOD
The blood is considered to be the only fluid tissue in the body. It is complex connective
tissue in which formed elements are suspended in a nonliving fluid matrix called plasma.
The plasma is the liquid part of the blood and is approximately 90% water.
3 formed elements in the blood
1. Erythrocytes- responsible for blood gas transport
2. Leukocytes defends body from infection or disease
3. Platelets- needed for normal blood clotting
(in this case, platelets are the ones mostly affected by the dengue virus so this will be our
focus)

Blood cell formation/hematopoieses (platelets)

Hematopoieses occurs in the red bone marrow or the myeloid tissue. Red bone
marrow is found chiefly in flat bones like the skull, pelvis, the ribs, sternum, humerus and
femur. All of the formed elements arise from a common type of stem cell called
hemocytoblast which resides in the red bone marrow

DENGUE HEMORRHAGIC FEVER

The hemocytoblast stem cells develop into lymphoid or myeloid stem cells.
Myeloid stem cells by then will developed as platelets or other formed elements
depending on the response of the changing body needs and different stimuli. Like
any other formed elements in the blood, platelet production is stimulated by the
hormones. The hormone thrombopoietin accelerates the production of platelets
but only little is known about how this process is regulated

PLATELETS
Platelets are not cells in a strict sense. They are fragments of bizarre
multinucleated cells of megakaryocytes. They appear as darkly stained and irregularly
shaped. The nominal platelet count is 150,000 500,000 per cubic millimeter.

PHYSIOLOGY OF PLATELETS

Platelets are responsible for normal blood clotting. If we are going to live without
it, a single cut would lead us out to death. There is a process called hemostasis wherein
platelets have a major role. Hemostasis means stooping of bleeding. It happens when a
blood vessel breaks or injured. Hemostasis occurs in three major phases which occur in
rapid sequence.

DENGUE HEMORRHAGIC FEVER

1. Vascular spasms occur the immediate response of the body to blood vessel
injury
2. Platelet plug forms when the endothelium is broken, the collagen fibers are
exposed that leads to clinging of the platelets to the damage site and making
them sticky. Platelets released more chemicals that attract more platelets to the
site of damage.
3.

Coagulation event occurs

A. Injured tissues released tissue factors (TF), substances that plays an
important role in clotting.
B. PF3 which is a phospholipid, coats the surfaces of the platelets,
interacts with the TF, Vit K, calcium ions and other protein clotting
factor
C. Prothrombin activator for conversion of prothrombin to thrombin
which is an enzyme.
D. Thrombin joins fibrinogen proteins to form long hair like molecules of
insoluble fibrin which forma netlike meshworks that traps RBCs and
forms the basis of the clot.

BONE MARROW

The bone marrow is the site of hematopoiesis, or blood cell formation. In a child all
skeletal bones are involved, but as the child ages marrow activity decreases. By

DENGUE HEMORRHAGIC FEVER

adulthood, marrow activity is usually limited to the pelvis, ribs, vertebrae, and sternum.
Marrow is one of the largest organs of the body, making up 4% to 5% of total body
weight. It consists of islands of cellular components (red marrow) separated by fat
(yellow marrow). As the adult ages, the proportion of active marrow is gradually replaced
by fat; however, in the healthy person, the fat can again be replaced by active marrow
when more blood cell production is required. In
adults with disease that causes marrow destruction, fibrosis, or scarring, the liver and
spleen can also resume production of blood cells by a process known as extramedullary
hematopoiesis. The marrow is highly vascular. Within it are primitive cells called stem
cells. The stem cells have the ability to self-replicate, thereby ensuring a continuous
supply of stem cells throughout the life cycle. When stimulated to do so, stem cells can
begin a process of differentiation into either myeloid or lymphoid stem cells. These stem
cells are committed to produce specific types of blood cells. Lymphoid stem cells
produce either T or B lymphocytes.Myeloid stem cells differentiate into three broad cell
types: RBCs,WBCs, and platelets. Thus, with the exception of lymphocytes, all blood
cells are derived from the myeloid stem cell. A defect in the myeloid stem cell can cause
problems not only with WBC production but also with RBC and platelet production. The
entire process of hematopoiesis is highly complex.

PLATELETS (THROMBOCYTES)

Platelets, or thrombocytes, are not actually cells. Rather, they are granular fragments of
giant cells in the bone marrow called megakaryocytes. Platelet production in the marrow
is regulated in part by the hormone thrombopoietin, which stimulates the production and
differentiation of megakaryocytes from the myeloid stem cell. Platelets play an essential
role in the control of bleeding. They circulate freely in the blood in an inactive state,
where they nurture the endothelium of the blood vessels, maintaining the integrity of the
vessel. When vascular injury does occur, platelets collect at the site and are activated.
They adhere to the site of injury and to each other, forming a platelet plug that
temporarily stops bleeding. Substances released from platelet granules activate
coagulation factors in the blood plasma and initiate the formation of a stable clot

DENGUE HEMORRHAGIC FEVER

composed of fibrin, a filamentous protein. Platelets have a normal life span of 7 to 10

days.

PLASMA AND PLASMA PROTEINS

After cellular elements are removed from blood, the remaining liquid portion is called
plasma. More than 90% of plasma is water. The remainder consists primarily of plasma
proteins, clotting factors (particularly fibrinogen), and small amounts of other substances
such as nutrients, enzymes, waste products, and gases. If plasma is allowed to clot, the
remaining fluid is called serum. Serum has essentially the same composition as plasma,
except that fibrinogen and several clotting factors have been removed in the clotting
process. Plasma proteins consist primarily of albumin and globulins. The globulins can be
separated into three main fractionsalpha, beta, and gammaeach of which consists of
distinct proteins that have different functions. Important proteins in the alpha and beta
fractions are the transport globulins and the clotting factors that are made in the liver. The
transport globulins carry various substances in bound form around the circulation. For
example, thyroid-binding globulin carries thyroxin, and transferrin carries iron. The
clotting factors, including fibrinogen, remain in an inactive form in the blood plasma
until activated by the clotting cascade. The gamma globulin fraction refers to the
immunoglobulins, or antibodies. These proteins are produced by the well-differentiated
lymphocytes and plasma cells. The actual fractionation of the globulins can be seen on a
specific laboratory test (serum protein electrophoresis). Albumin is particularly important
for the maintenance of fluid balance within the vascular system. Capillary walls are
impermeable to albumin, so its presence in the plasma creates an osmotic force that keeps
fluid within the vascular space. Albumin, which is produced by the liver, has the capacity
to bind to several substances that are transported in plasma (eg, certain medications,
bilirubin, some hormones). People with poor hepatic function may have low
concentrations of albumin, with a resultant decrease in osmotic pressure and the
development of edema.

DENGUE HEMORRHAGIC FEVER

PATHOPHYSIOLOGY

Predisposing factors
Geographical area:
Caloocan city

Precipitating factors
Environmental conditions
(stagnant water as breeding sites)
Dengue carrier mosquitoes
Activity (student)

Replication of virus in mosquitoes

salivary glands

Bite to skin from dengue carrier mosquito (itchiness and

redness at the bite area)

Macrophages performs phagocytosis; dengue virus

replicates within the cells, antibodies attach to viral
antigents

DENGUE HEMORRHAGIC FEVER

Dengue virus is inoculated in the blood with 8 -14 days incubation

period

Virus disseminates rapidly in the blood stimulating WBCs and

B lymphocytes and produces antibodies and macrophages

Release of cytokines and other

platelet activating factors that
stimulates WBCs and pyrogen
release

Entry to the spleen

Entry to the bone

marrow

DENGUE
s/s:

High grade fever

Flushed skin
Headache
Pink rashes on the skin

If Treated:
HYDRATION: IV
infusion; increased
fluid intake
Drug therapy:
antipyretic
(Paracetamol)
Careful monitoring
condition

RECOVERY
DENGUE HEMORRHAGIC FEVER

If not treated:
Complications such:
Intense bleeding
Severe hypertension
Pulmonary edema
Shock
Liver cirrhosis

DEATH

INTRODUCTION

Dengue Fever is caused by one of the four closely related, but antigenically distinct,
virusserotypes 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 toonly that serotype of life, to a person living in a Dengue-endemic area can
have more than oneDengue infection during their lifetime. Dengue fever through the
four different Dengue serotypesare maintained in the cycle which involves humans and
Aedes aegypti or Aedes albopictusmosquito 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 Dengueand after a week it can transmit the
virus while biting a healthy person. Dengue cannot betransmitted or directly spread from
person to person. Aedes aegypti is the most common aedesspecie 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:
First 4 days:
>febrile or invasive stage --- starts abruptly as high fever, abdominal pain and headache;
later flushing which may be accompanied by vomiting, conjunctival infection and
epistaxis
4th to 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 to 10th day:
>convalescent or recovery stage --- generalized flushing with intervening areas
of blanching appetite regained and blood pressure already stable

DENGUE HEMORRHAGIC FEVER

MODE OF TRANSMISSION:
Dengue viruses are transmitted to humans through the infective bites of female
Aedesmosquito. 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. Aedesmosquito may have acquired the virus when they fed on an individual during
this period. Dengue cannot be transmitted through person to person mode.

Symptoms
Early symptoms of dengue hemorrhagic fever are similar to those of dengue fever, but
after several days the patient becomes irritable, restless, and sweaty. These symptoms are
followed by a shock-like state.
Bleeding may appear as pinpoint spots of blood on the skin (petechiae) and larger patches
of blood under the skin (ecchymoses). Bleeding may occur from minor injuries. Shock
may cause death. If the patient survives, recovery begins after a one-day crisis period.
Early symptoms include the following:

Fever

Headache

Muscle aches

Joint aches

Malaise

Decreased appetite

Vomiting

DENGUE HEMORRHAGIC FEVER

Acute phase symptoms include the following:

Shock-like state

Sweaty (diaphoretic)

Cold, clammy extremities

Restlessness followed by:

o Worsening of earlier symptoms

o Petechiae
o Ecchymosis
o Generalized rash
The severity of DHF is categorized into four grades: grade I, without overt bleeding but positive
for tourniquet test; grade II, with clinical bleeding diathesis such as petechiae, epistaxis and
hematemesis; grade III, circulatory failure manifested by a rapid and weak pulse with narrowing
pulse pressure ( less than 20 mmHg) or hypotension, with the presence of cold clammy skin and
restlessness; and grade IV, profound shock in which pulse and blood pressure are not detectable.

Category I

Category II

Category III

Category IV

History or

Category I plus Presence of

Category II plus

Category III

presence of

one or more Danger Signs

Circulatory failure

plus profound

fever 2-7 days

(especially defervescence)

Cold clammy skin

shock with

duration, with a

Restlessness

Weak thready pulse

undetectable

(+) tourniquet

Changes in sensorium

Narrow pulse

pulse and blood

test or presence

Cold, clammy skin

pressure ( less than

pressure

of skin flushing

Sudden onset of abdominal

20mm/Hg)

or petechial rash painDifficulty of breathing

Circumoral cyanosis
Seizures
Spontaneous bleeding (gum
bleeding, epistaxis, rashes,
petechiae)

Hypotension
Restlessness

NURSING HEALTH HISTORY

A. personal history
Name: LD
Age: 50
Address: Padrigal St, Karuhatan. City of Valenzuela.
Birth day: December 17, 1963
Sex: female
Civil status: married
Religion: roman Catholic
Attending physician: Dr. Salvadi
Admission diagnosis: Dengue fever with symptoms
Admission date: December 4, 2014
Chief complaint: Fever

B. history of present illness

Patient complained of fever since Friday midnight until Saturday accompanied with body
weakness. No consult was done and when it was accompanied with body malaise hence
admission.

C. past medical history

Patient was healthy but he had been admitted to the hospital several times before. His last
admission was 1986 for appendectomy after 6months readmission for tuberligation. Then 1998
patient was diagnosed with ovarian cyst and a laser surgery was done.

D. personal/social history
Patient is married with 3 kids. Non-smoker but drinks alcohol occasionally.

E. Family health history

(+) HPN

(+) CANCER (-) DM (-) GOITER

LABORATORY TEST
URINALYSIS RESULT

Physical Appearance
Test

Result

Normal

Color

Yellow

Yellow

Transparency

Slightly hazy

Clear

Reaction PH

6.0

4.6 - 8.0

Specific Gravity

1.030

1.010 1.035

Sugar

Negative

Absent

Protein

Negative

Absent

Microscopic
Test

Result

Normal

Pus Cell

0-3

Absent

RBC

0-1

0-5

Epithelial Cells

Occasional

Protein

Negative

Absent

BLOOD ANALYSIS
Test

Actual findings

Normal findings

Analysis/interpretation

Hemoglobin

147

125-160

Normal

Hematocrit

0.447

0.38-0.50

Normal

Erythrocytes

4.98

4.5-5.0

Normal

MCV

91

80-100

Normal

MCH

30.0

27.0-32.0

Normal

MCHC

329

320-360

Normal

Total WBC

2.7

5.0-10.0

The no. of WBC count

decreased indication of
vulnerable to potential serious
infection which is dengue

Nuetrophils

0.34.9

0.55-0.65

The neutrophils are low

because it helps in fighting the
dengue virus.

Lymphocytes

46.6

20-40

High due to the virus

Monocytes

17.6

2-10

High due to the virus

Platelet count

123

150-450

The no of platelet is decrease

because the dengue virus
attacks the platelet and the
patient is at risk for bleeding

COURSE IN THE WARD

A 50-year-old patient accompanied by sister was admitted with a chief complaint of fever, seen
and examined by doctor salvadi. Admitted in phil health. No vomiting or abdominal pain noted.
The patient had a fever of 38.50C and BP: 150/80 PR: 72, RR: 18. Diet as tolerated was ordered
except dark colored food. Doctor ordered to start IV infusion PNSS 1Lx8hrs, paracetamol
500mg tab Q8 of fever 38.9 and also a CBC with platelet OD and serum electrolyte test was
ordered by doctor. Consent for admission was signed and relative was instructed to perform TSB
and encouraged to increase OFI.

OUR LADY OF FATIMA UNIVERSITY

College of Nursing

In Partial Fulfillment of Requirements for RLE 107b

DENGUE HEMORRHAGIC
FEVER
An Individual Case Study

Presented To:
MAAM ANTONIO MAN, RN

Submitted By:
IDI FAITH AFOKE
BSN 4Y2-1B.

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.
Dont give aspirin and NSAIDs, 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
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 prevention)> 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.> UUse 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 patients 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 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)
Spirituality: Advise the family to help the patient to stay positive and pray to God.

PHYSICAL ASSESSMENT (Gordon 11 functional assessment)

HEALTH PERCEPTION- HEALTH MANAGEMENT PATTERN
1. Mental status
a. oriented to time, place and person
b. sensorium: alert
c. memory: recent
2. Vision
Pupil size normal
Pupil reaction normal
3. Hearing : No hearing aids
4. Cerebrellar exam: Normal
5. Reflexes: normal
6. No enlarged lymph nodes on neck.
7. General appearance
a. Hair: black
b. Skin: pale
c. Nail: normal
d. Body odor: none
NUTRITIONAL-METABOLIC PATTERN
1. Skin: warm, no lesion, no rash, firm turgor, pale colour
2. Mucous membrane
a. Mouth: moist, no lesions, pink color, normal teeth, no dentures, normal gums and
tongue.
b. Eyes: moist, pale conjunctiva, no lesion
3. Edema: none
4. Normal thyroid
5. No jugular vein distention
6. Gag reflex: present
7. Can patient move easily: no, due to body weakness
8. Upon admission was patient dressed appropriately for weather: yes

ELIMINATION PATTERN
1. Normal bowel sounds
2. Palpate abdomen: Not tender, Soft to touch, No masses, distention or ostomy present

ACTIVITY-EXERCISE PATTERN
1. Cardiovascular:
a. No cyanosis
b. Radial, femoral and popliteal pulse are present
c. Extremities: warm, capillary refill normal, pink color, normal nail beds, hair
distribution normal.
d. Heart: rhythm and sounds are normal
2. Respiratory: shallow, no cough, no fremitus no chest excursion.
3. Musculoskeletal: normal ROM, gait, balance and muscle mass.
Normal posture, no deformities, no missing limbs, no tremors, no paralysis and
developmental assessment is normal.

SLEEP REST PATTERN

1. Sleeps 6 hours aday with naps and feels rested.
2. No insomnia, no difficulty sleeping and awakening.

COGNITIVE-PERCEPTUAL PATTERN
1. No overt sign of pain
2. Pain is located at the head, scale of 5, not radiating

SELF PERCEPTION AND SELF-CONCEPT PATTERN

1. During assessment pain remained calm and cooperative.
2. No voice change or reddened face.

ROLE-RELATIONSHIP PATTERN
1. Speech pattern
a. English is not patients first language, speaks tagalog

b. No speech problem was noted during interview.

2. No dysfunctional family interaction was note.

SEXUALITY-REPRODUCTIVE PATTERN
1. Last LMP: October 1-5, 2014
2. Does not use birth control measure
3. No history of vaginal bleeding
4. Has not done pap smear or mammogram before.
5. No history of STD

COPING-STRESS TOLERANCE PATTERN

Overt sign noted was rubbing of head.

VALUE-BELIEF PATTERN
1. Catholic Religion
2. Admission will not interfere with spiritual practices
3. Does not have any religious restrictions of diet