Dengue Hemorrhagic Fever

Dengue Hemorrhagic Fever (DHF) are acute febrile diseases which occur
in the tropics, can be life-threatening, and are caused by four closely related virus
serotypes of the genus Flavivirus, family Flaviviridae. It is also known as
breakbone fever, since it can be extremely painful. It occurs widely in the tropics,
including northern Argentina, northern Australia, Bangladesh, Barbados, Bolivia,
Belize, Brazil, Cambodia, Colombia, Costa Rica, Cuba, Dominican Republic,French
Polynesia, Guadeloupe, El Salvador, Guatemala, Guyana, Haiti, Honduras, India,
Indonesia, Jamaica, Laos, Malaysia, Melanesia, Mexico, Micronesia, Nicaragua,
Pakistan, Panama, Paraguay, Philippines, Puerto Rico, Samoa, Western Saudi Arabia,
Singapore, Sri Lanka, Suriname, Taiwan, Thailand, Trinidad, Venezuela and Vietnam,
and increasingly in southern China. Unlike malaria, dengue is just as prevalent in
the urban districts of its range as in rural areas. Each serotype is sufficiently
different that there is no cross-protection and epidemics caused by multiple
serotypes (hyperendemicity) can occur. Dengue is transmitted to humans by the
Aedes (Stegomyia) aegypti or more rarely the Aedes albopictus mosquito, both of
which feed exclusively during daylight hours.
CAUSATIVE AGENT

Dengue Hemorrhagic Fever is caused due to infection with a virus of

the Flaviviridae family. The agency through which the virus travels is the aedes
aegypti or the aedes albopictus mosquito.

MODE OF TRANSMISSION

Dengue viruses are transmitted to humans

through the bites of infective female Aedes
mosquitoes. Mosquitoes generally acquire the virus
while feeding on the blood of an infected person. 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.

Infected humans are the main carriers and multipliers of the virus, serving as
a source of the virus for uninfected mosquitoes. The virus circulates in the blood of
infected humans for two to seven days, at approximately the same time that they
have a fever; Aedes mosquitoes may acquire the virus when they feed on an
individual during this period. Some studies have shown that monkeys in some parts
of the world play a similar role in transmission.

INCUBATION PERIOD

After being bitten by a mosquito carrying the virus, the incubation period
ranges from three to 15 (usually five to eight) days before the signs and symptoms
of dengue appear abruptly. The initial symptoms of dengue fever last about six to
seven days. The fever climbs rapidly in the first 48 to 96 hours of the illness and
then may break for a day before elevating rapidly again. This second phase of the
fever is often when a rash may appear on the limbs or chest.

PERIOD OF COMMUNICABILITY

Unknown. Presumed to be on the 1st week of illness—when virus is still

present in the blood.
SIGNS AND SYMPTOMS

The classic dengue rash is a generalised maculopapular rash with islands of

sparing. A hemorrhagic rash of characteristically bright red pinpoint spots, known
as petechiae can occur later during the illness and is associated
withthrombocytopenia. It usually appears first on the lower limbs and the chest; in
some patients, it spreads to cover most of the body. There may also be severe
retro-orbital pain, (a pain from behind the eyes that is distinctive to Dengue
infections), and gastritis with some combination of associated abdominal
pain, nausea, vomiting coffee-grounds-like congealed blood, or severe diarrhea.

An acute febrile infection of sudden onset with clinical manifestationof 3 stages:

• 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-7th days—Toxic or hemorrhagic stage—lowering of temperature, severe
abdominal pain, vomiting and frequent bleeding from gastrointestinal tract in
the form of hematesis or melena. Unstable BP, narrow pulse pressure and
shock may occur. Tourniquet test which may be negative due to low or
vasomotor collapse.
• 7th-10th days—convalescent or recovery stage generalized flushing with
intervening areas of blanching appetite regained and blood pressure already
stable.

Classification

• Severe, frank type—with flushing, sudden high fever, severe hemorrhage,

followed by sudden drop of temperature, shock and terminating in recovery
or death.
• Moderate—with high fever but less hemorrhage, no shock
• Mild—with slight fever, with or without petechial hemorrhage but
epidemiologically related to typical cases usually discovered in the course of
investigation of typical cases

Grading of Dengue Fever

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 (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. It is noteworthy that patients who are in threatened shock or
shock stage, also known as dengue shock syndrome, usually remain
conscious.
• Grade III and IV are considered to be Dengue Shock Syndrome
LABORATORY/DIAGNOSIS

1.) Tourniquet Test (Rumpel Leads Tests)

• Inflate the blood pressure cuff on the uppe
r arm to a point midway between the
systolic and diastolic pressure for 5 minute
s
• Release cuff and make an imaginary 2.5 c
m square or 1 inch just below the cuff, at
the antecubital fossa
• Count the number of petechiae inside the
box
• A test is (+) when 20 or more petechiae
per2.5 cm square or 1 inch square are
observed.

2.) A confirmed diagnosis is established by culture of the virus, polymerasechain-

reaction (PCR) tests, or serologic assays.

The diagnosis of dengue hemorrhagic fever is

made on the basis of the following triad of symptoms
and signs: Hemorrhagic manifestations; a platelet
count of less than 100, 000 per cubic millimeter; and
objective evidence of plasma leakage, shown either by
fluctuation of packedcell volume (greater than 20
percent during the course of the illness) or by clinical
signs of plasma leakage, such as pleural effusion,
ascites or hypoproteinemia. Hemorrhagic
manifestations without capillary leakage do not
constitute dengue hemorrhagic fever.

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. Dengue infection can
affect many organs and thus may present unusually as liver dysfunction, renal
impairment, meningo-encephalitis or gastroenteritis.

1. Fever, headaches, eye pain, severe dizziness and loss of appetite.

2. Hemorrhagic tendency (positive tourniquet test, spontaneous bruising,
bleeding from mucosa, gingiva, injection sites, etc.; vomiting blood, or bloody
diarrhea)
3. Thrombocytopenia (<100,000 platelets per mm³ or estimated as less than 3
platelets per high power field)
 4. 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)
5. Encephalitic occurrences.

Dengue shock syndrome is defined as dengue hemorrhagic fever plus:

• Weak rapid pulse,

• Narrow pulse pressure (less than 20 mm Hg)
• Cold, clammy skin and restlessness

TREATMENT

Only symptoms may be treated, as Dengue Hemorrhagic Fever is triggered

by a virus that yet does not have a specific cure.

• Electrolyte imbalances are corrected by electrolytes and Intravenous

Fluids.

• Fresh blood transfusion helps in correcting in any bleeding troubles.

• Blood oxygen levels must be treated as they tend to get very low.
Oxygen therapy is usually necessary.

Because dengue fever is caused by a virus, there is no specific medicine or

antibiotic to treat it. For typical dengue, the treatment is purely concerned with
relief of the symptoms (symptomatic). Rest and fluid intake for adequate hydration
is important. Aspirin and nonsteroidal anti-inflammatory drugs should only be taken
under a doctor's supervision because of the possibility of worsening hemorrhagic
complications. Acetaminophen(Tylenol) and codeine may be given for severe
headache and for the joint and muscle pain (myalgia).

NURSING MANAGEMENT

Supportive and symptomatic treatment should be provided:

• Promote rest
• Medication
 Paracetamol – for fever
 Analgesic (Acetaminophen (Tylenol) and codeine) – for severe
headache and joint and muscle pains
 Aspirin and nonsteroidal antiinflammatory drugs should be avoided
• Rapid replacement of body fluids is the most important treatment
  Give ORESOL to replace fluid as in moderate dehydration at 75ml/kg in
46 hours or up to 23L in adults. Continue ORS intake until paient’s
condition improves.
 Intravenous fluid
• For hemorrhage
 Keep patient at rest during bleeding periods
 For epistaxis – maintain an elevated position of trunk and promote
vasoconstriction in nasal mucosa membrane through an ice bag over the
forehead.
 For melena – ice bag over the abdomen. Provide support during the
transfusion therapy

• Diet
 Low fat, low fiber, nonirritating, noncarbonated
 Noodle soup may be given

• Observe signs of deterioration (shock) such as low pulse, cold clammy

perspiration, prostration.

• For shock
 Place in dorsal recumbent position to facilitate circulation
 Provision of warmth through lightweight covers (overheating causes
vasodilatation which aggravates bleeding)

HEALTH TEACHINGS

The best way to prevent dengue fever is to take special precautions to

avoid contact with mosquitoes.

• Eliminate vector by:

 Changing water and scrubbing sides of lower vases once a week
 Destroy breeding places of mosquito by cleaning surroundings
 Proper disposal of rubber tires, empty bottles and cans
 Keep water containers covered

Because Aedes mosquitoes usually bite during the day, be sure to use
precautions
especially during early morning hours before daybreak and in the late aftern
oon before dark.

Other precautions include:

• When outdoors in an area where dengue fever has been found

 Use a mosquito repellant containing DEET, picaridin, or oil of lem
on eucalyptus
  Dress in protective clothinglongsleeved shirts, long pants, socks,
and shoes

• Keeping unscreened windows and doors closed

• Keeping window and door screens repaired
• Use of mosquito nets

EMILIO AGUINALDO COLLEGE MANILA

SCHOOL OF NURSING AND MIDWIFERY

IN PARTIAL FULFILLMENT TO THE SUBJECT

N105 (Leadership and Management) RLE

RESEARCH INSTITUTE FOR TROPICAL MEDICINE

“DENGUE HEMORRHAGIC FEVER”

A CASE ANALYSIS
 Submitted By:
REYNALDO S. DIÑO
07-1-65333
Section 6
Group B