Nursing Diagnosis Case Study Dengue

OBJECTIVES

General

This case presentation aims to identify and determine the general heath problems and needs of the patient with an admitting diagnosis of Dengue Hemorrhagic Fever, Type 1. This presentation also intends to help patient promote health and medical understanding of such condition through the application of the nursing skills.

Specific

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

Dengue fever is an infectious disease carried by mosquitoes and caused by any of four related dengue viruses. 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. Health experts have known about dengue fever for more than 200 years.

INTRODUCTION

Dengue fever is found mostly during 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

An epidemic in Hawaii in 2001 is a reminder that many states in the United States are susceptible to dengue epidemics because they harbor the particular types of mosquitoes that transmit it. Worldwide, more than 100 million cases of dengue infection occur each year. This includes 100 to 200 cases reported annually to the Centers for Disease Control and Prevention (CDC), mostly in people who have recently traveled abroad. Many more cases likely go unreported because some health care providers do not recognize the disease. During the last part of the 20th century, many tropical regions of the world saw an increase in dengue cases. Epidemics also occurred more frequently and with more severity. In addition to typical dengue, dengue hemorrhagic fever and dengue shock syndrome also have increased in many parts of the world.

Dengue fever can be caused by any one of four types of dengue virus: DEN-1, DEN-2, DEN-3, and DEN-4. You can be infected by at least two, if not all four types at different times during your lifetime, but only once by the same type.

You can get dengue virus infections from the bite of an infected Aedes mosquito. Mosquitoes become infected when they bite infected humans, and later transmit infection to other people they bite. Two main species of mosquito, Aedes aegypti and Aedes albopictus, have been responsible for all cases of dengue transmitted in this country. Dengue is not contagious from person to person.

Symptoms of typical uncomplicated (classic) dengue usually start with fever within 5 to 6 days after you have been bitten by an infected mosquito and include

  • High fever, up to 105 degrees Fahrenheit
  • Severe headache
  • Retro-orbital (behind the eye) pain
  • Severe joint and muscle pain
  • Nausea and vomiting
  • Rash

The rash may appear over most of your body 3 to 4 days after the fever begins. You may get a second rash later in the disease. Symptoms of dengue hemorrhagic fever include all of the symptoms of classic dengue plus

  • Marked damage to blood and lymph vessels
  • Bleeding from the nose, gums, or under the skin, causing purplish bruises

This form of dengue disease can cause death.

Symptoms of dengue shock syndrome-the most severe form of dengue disease-include all of the symptoms of classic dengue and dengue hemorrhagic fever, plus

  • Fluids leaking outside of blood vessels
  • Massive bleeding
  • Shock (very low blood pressure)

This form of the disease usually occurs in children (sometimes adults) experiencing their second dengue infection. It is sometimes fatal, especially in children and young adults.

What Do You Think?

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Transcript of DENGUE FEVER

Dengue Fever is caused by one 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.
a person living in a Dengue-endemic area can have more than one Dengue infection during their lifetime
involves humans and Aedes aegypti or Aedes albopictus mosquito through the transmission of the viruses to humans by the bite of an infected mosquito
STATISTICS
National Epidemiology Center of the Philippines' Department of Health reports a total of 59,943 dengue cases from January 1 to September 6, 2014. This is 59.57% lower compared to the same time period last year (148,279).
Region III --- 8.01% respectively, to the overall figure

NURSE CENTERED OBJECTIVES
Physical Assessment
BOOK-BASED
PERSONAL HISTORY
The END.
Dengue Fever
Nursing
History

DISCHARGE PLAN
DENGUE FEVER
a case study
Group 1
What is Dengue?
DEMOGRAPHIC
SOCIO-ECONOMIC
" Baby Girl" - The group decided to use the name “baby girl” to hide the identity of the client, not because of her age but because of the observed relationship to her mother. She was often supervised and cared for like a baby during her confinement in AMC.
("alagang-alaga")
Six years old, Birthday - July 19, 2008
Grade one student - Achiever's
Youngest of four children
second girl in the family.
Family Business
Truck Rental Service
They approximately make an income of 250,000 pesos per month.
They rent their truck services to large corporations
THE PATIENT AND HIS CARE
ANATOMY &
PHYSIOLOGY
BLEEDING
INFECTION
FLUID VOLUME DEFICIT
& LEARNING DERIVED
cognitive
psychomotor
Affective
a) Understand the definition and pathophysiology of Dengue Fever (DF).
b) Recall key concepts regarding the care for a patient with Dengue Fever.
c) Review necessary assessment techniques in handling a patient with DF.
d) Prioritize the patient’s needs according to manifested signs and symptoms.
e) Anticipate the potential problems which may occur with DF.
After 2 -3 days of handling a client with dengue fever, the nursing students will be able to:
a) Conduct a cephalocaudal assessment on a patient with DF.
b) Evaluate relevant diagnostic results to further understand the current condition of the patient.
c) Create a book-based and client-centred pathophysiology using multiple sources.
d) Examine and analyze the current (medical and nursing) course of treatment for the patient with DF
e) Create 5 or more (if applicable) nursing care plans, according to actual patient needs and assessment findings.
f) Create a discharge plan for a patient with dengue fever.
a) Display eagerness to learn the concept of DF
b) Display appropriate attitudes relating to the concepts of care while handling a patient with DF.
Religious Affiliation
Cultural Factors Affecting the Health of the Family
Family Health-Illness History
HISTORY OF...
The patient has not been previously confined for any reason. She experiences the common cold or flu every once in a while, but this is her first confinement. The patient has no currently diagnosed co-morbid conditions to mention.
Past Illness
DIAGNOSTIC & LABRATORY PROCEDURES
DIAGNOSTIC & LABRATORY PROCEDURES
Before
During
After
NURSING RESPONSIBILITIES
PATHOPHYSIOLOGY
SCHEMATIC DIAGRAM
SYNTHESIS OF THE
DISEASE
PREDISPOSING &
PRECIPITATING FACTORS
SIGNS & SYMPTOMS
CLIENT-BASED
PATHOPHYSIOLOGY
SCHEMATIC DIAGRAM
PREDISPOSING &
PRECIPITATING FACTORS
SIGNS & SYMPTOMS
MEDICAL
ACTIVITY
DRUGS
DIET
NURSING RESPONSIBILITIES
BEFORE, DURING, AND AFTER
Management
Description
Purpose
Date Ordered
Client's
Response
IVF #1 D5LRS 1L x 18 gtts/min
5% Dextrose in Lactated Ringer’s Solution

Hypertonic Nonpyrogenic, parenteral fluid, electrolyte and nutrient replenisher

Administered intravenously, has value as a source of water, electrolytes and calories or as an alkalanizing agent.
Treatment for persons needing extra calories who cannot tolerate fluid overload.

Treatment for shock

It helps to prevent dehydration to the pt.
11/24/2014

11/ 25/ 2014
Client was able to tolerate the treatment well, with no signs of distress or adverse reactions (redness of the site, swelling, etc.)
NURSING CARE PLANS
IMPAIRED
SKIN INTEGRITY
risk for
risk for
risk for
risk for
1
2
3
4
Cues
NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
NURSING
INTERVENTION
& RATIONALE
EVALUATION
Cues
NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
NURSING
INTERVENTION
& RATIONALE
EVALUATION
Cues
NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
NURSING
INTERVENTION
& RATIONALE
EVALUATION
Cues
NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
NURSING
INTERVENTION
& RATIONALE
EVALUATION
M
E
T
H
O
D
DISCHARGE PLAN
LEARNING DERIVED
ENA
MARIELOU
ANGELICA
MOMMY EMMA
CHEVY
PIA
Thank you for listening!
references
Carpenito, L. (2009). Nursing care plans & documentation: Nursing diagnoses and collaborative problems (5th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Dengue guidelines for diagnosis, treatment, prevention, and control. (New ed.). (2009). Geneva: TDR.
Guerrant, R. (2011). Tropical infectious diseases principles, pathogens and practice (3rd ed.). Edinburgh: Saunders/Elsevier.
Halstead, S. (2008). Dengue. London: Imperial College Press ;.
Kyle, T. (2008). Essentials of pediatric nursing. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Pathophysiology: A 2-in-1 reference for nurses. (2005). Philadelphia: Lippincott Williams & Wilkins.
Setiati, T. (2006). Dengue virus infection: Clinical assessment, pathophysiology and management.
Timby, B. (2009). Fundamental nursing skills and concepts (9th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
In this exposure, I learned that as a student nurse,
we should know all our responsibilities
, especially to our patients. In this duty it also
improves my communication skills
to our patient especially with children in the Pedia Ward and also in this exposure it also
improves my knowledge and skills in such as administering medications
through IVF and also in monitoring the needs of our patients, taking vital signs and I also learn that before we give or administer any medication we should also know what are the rights in giving the medications.
After the 1st rotation of duty at AMC in OB and Pedia ward, I’ve learned a lot of things about the cases we’ve handled. I could say that I have improved as a student nurse. I learned how to prepare, administer and document medications. I understand better the patient’s chart than before and I start to analyze more on what independent nursing interventions I can give. I must admit that I had a hard time at first but as time passes by, I gradually get used to the routines we do at the hospital. In addition, it’s actually our first time at the Pedia ward so, I find it hard to deal with younger patients because some of them are “not-so-friendly” to us and most of the time, and we just ask the S.O. regarding the patient’s condition. Our FDAR also improved a lot and our communication skills are also good.
I learned in our case study that dengue fever nowadays is not an occasional illness but it’s all-year round. Also, the no. 1 prevention in this case in cleanliness, if we maintain a clean environment, we might get less likely this illness. I learned also how to detect someone who has dengue by just simply knowing it’s signs and symptoms and the nursing interventions I must give. To sum it all up, I gained so much knowledge from this experience.
CHERRY
Since it was our 2nd time to have duty in the hospital we all have an idea on what are we going to do to. I learned many things. Sometimes I feel uncomfortable especially if there is a nurse looking and observing on what are we doing but then I realize that they are like that because they want us to learn: how to communicate well with our client and how to apply the nurse and patient interaction. I developed my communication skills in this rotation because we were able to experience handling an individual patient. I learned how to be responsible in giving patient medication and how to check there vital signs. I also learned how to be patient, especially if your client is a pediatric case. We need to be patient because some kids have difficulty complying with treatment because they are afraid. We need to be patience and understand them. On this rotation I learned all these things.
The mother in our case study was very in tune with her daughter’s health care needs, immediately knowing that something was wrong when she “stopped being herself.” From careful assessments and appropriate measures rendered,
the patient was very lucky that her only symptom was fever.
Considering her illness,
it could have been much worse
, and
many children continue to suffer and die from this disease because of the delay in medical treatment.

This is an aspect of learning that I hope to pass on to any patients that I handle in the future ---
to get early screening and preventive medicine.
It is
a common mistake of Filipinos to wait the last minute before getting treatment
, and more often than we would like to admit, a majority of people
only seek medical treatment when their case is so severe
that they indefinitely require hospitalization. In all cases, it is most definitely better to be “safe” than “sorry.”
First I learned the signs and symptoms of Dengue and the general condition of it. I also learned how to administer medications and the doses of the medicines although at first it makes me nervous. I learned the different grades of dengue fever and the difference of each grades. I learned that it needs to be careful for giving medications and know first the route of medications. I also learned the Diet that is to be given to the dengue patient and the meaning of that diet give to the patient and I also learned the foods that the patient need to avoid when the patient has a dengue fever. I also learned how to read a lab tests especially the platelet count of the patient when it is low or in high count and last I also learned how to communicate to others and how to establish rapport to the patient and to the SO.
During this first experience, I was very worried because I saw my patient --- how she was suffering due to illness, how she was crying, and not talking to us because I think she was anxious and fearful of her conditions and surroundings. I emphasized with her, and the mother of the patient, because I am a parent too. I know the feeling of the parent of the children confined in the pediatric ward, and how they are worried. This is why I tried my best to comfort them, to give them an opportunity to relax and reassured them everything will be alright and that God always good to us and they listened. I also tried my best to empower the mother and the patient through giving heath teaching.
After six weeks of actual duty in the Pediatric and OB ward, I learned and experienced a lot of different things such as on how to administer a medication through IV push. At first, I was nervous. My hand was shaking a little while administering the medication because I was worried that I might hurt the patient. I also learned on how to compute medications, regulate IV fluids, read and interpret lab results, and administer medications properly. I/We handled patients with different kinds of diseases such like Pneumonia, Bronchitis, AGE (Acute Gastroenteritis), Tonsillitis, UTI (Urinary Tract Infection), and Dengue. Since I had the chance to have a duty in the pediatric ward, we handled patients who are 1-6 years of age. It was kind of difficult to approach and take their vital signs because some of them were afraid of nurses. So, we have to be more patient and we must gain their trust. That’s how my communication skills improved and learned on how to communicate with children. Not only with children, but also with their SO. We chose to make a case study about Dengue. Through this case study, I really learned a lot about Dengue such as its definition, sign and symptoms, causes, pathophysiology, treatment, and prevention of the disease.
Not the actual patient
: Representation purposes only
Mother is a graduate of BS Commerce (HAU)
Father is an Engineer (HAU)
“Baby Girl” and her family are Roman Catholics, however, they seldom attend mass services and only attend mass during special occasions (such as Christmas and New Year).
The family believes in “herbalaryos”. Before taking their daughter to the hospital, they brought her daughter to a faith healer.
Hereditary Disease in the Family.
According to the patient’s mother, they do not have a history of any hereditary disease (up to third generation).
Existing Disease in the Family.

Currently, no one else in the family except the patient has illness.
Present Illness
The Patient’s
chief complaint is fever
.
The patient’s fever began the
Thursday before her confinement
. At first they though it was an ordinary fever, but the next day it and day after it kept reoccurring. Worried, the patient’s mother brought Baby girl for a consultation to their doctor. The patient was
admitted on November 24, 2014
as per advice of the doctor and request of the mother.
Admitting Assessment
Lifted from Chart
Date:
November 24, 2014
Time:
10:44 am (AMC ER)
Admitted a 6 year old female patient, conscious, coherent, cuddled by mom with a fever under the service of Dr. [Name of Doctor omitted]. (-) abdominal pain, (-) cough. For admission as per request of client’s mother.
"
"
first nurse patient
Interaction
Date:
November 25, 2014
Time:
7:30 am
Upon meeting the patient, she was quietly laying down on the hospital bed with her head slightly elevated. She wasn’t talking, and not even smiling. When we interviewed her mothers, she said that this was highly unusual, because she is usually talkative or “bibo.” She was wearing a hello kitty pajama, and always had her pillow on top of her lap (a hotdog pillow).
Appearance:
Vital Signs were taken as follows:
T
P
R
BP
90/60 mmHg
20 cpm
108 bpm
37.6 °C
NOVEMBER 25, 2014
HEAD:

(Within Normal Limits)
 Hair straight, Black in color, curly/wavy in texture, evenly distributed.
 Smooth scalp, no presence of lesions or scars; clean with no presence of lice and dandruff.
 Symmetrical facial movements.
EYES:
(Within Normal Limits)
 Symmetrical eyelids, pink conjunctiva.
 Periorbital region- no signs of swelling.
 Pink conjunctiva, anicteric sclera.
 (R) & (L) eyes have brisk reaction to light; uniform constriction and convergence.
NOSE:
(Within Normal Limits)
 Nasal septum is midline.
 Both nostrils patent.
 No signs of nasal discharge.
 Nasal mucosa pinkish in color.
 Sinuses are non-tender.
EARS:
 Symmetrical in size and shape, external auditory canal is dry.
 Normal voice tone is audible, no observed difficulties in hearing noted.
MOUTH:
 Lips are dry, cracking.
 Lips, gums mucosa are pinkish in color.
 Tongue midline, red in color, with presence of whitish patch on distal portion of tongue.
 Teeth complete no observable dental carries.
PHARYNX:
 Uvula is midline, not swollen.
 No observable problems with swallowing..
 Tonsils are not inflamed.
 Posterior pharynx not inflamed.
 Mucosa is pinkish in color.

NECK:
 Trachea midline.
 Thyroid non-palpable; no masses palpable on neck.
 Full range of movement; no stiffness or pain noted with movement.
UPPER EXTREMITIES:
 Full range of motion.
 No swelling or muscular tenderness noted for both arms.
 Skin is dry to touch, no paleness.
THORAX AND LUNGS:
 Symmetrical lung expansion; equal tactile fremitus noted.
 Resonant percussion across lung fields.
 No observed cough; clear breath sounds.
 Breathing is not labored.
ABDOMEN:
 Symmetrical in size and shape.
 Normoactive bowel sounds.
BOWEL AND BLADDER:
 Dark yellow (concentrated appearance), highly aromatic
 Normal frequency.

LOWER EXTREMITIES:
 No signs of swelling for both feet.
 No signs of bruising.
 No presence of varicosities.
 Skin is dry and smooth to touch.
 No presence of paleness, flushing
 Full range of motion.
SKIN:
 No signs of bruising.
 No paleness noted.
 Dry to touch, supple; no presence of lesions or scars.
 Skin turgor - 4 seconds.
 Capillary Refill - 4 seconds

2nd nurse patient
Date:
November 25, 2014
Time:
7:30 am
Interaction
Lifted from Chart
Received patient on bed, awake, conscious, and coherent, afebrile, (-) DOB, (-) epig pain, no s/sx of bleeding, no s/sx of distress with an ongoing IVF of d5LRS 1L x 18gtts/min regulated and infusing well.
"
"
On the second day, the patient seemed happier and better. She was more active, and was seen playing with her play money (she was pretending she was a cashier). She actually spoke on this day and said,
“Mommy, yun…”
when she was asking for help from her mother in reaching for something.
Appearance:
t
p
r
bp
36.7 °C
90/60 mmHg
24 cpm
96 bpm
Vital Signs were taken as follows:
focus assessment findings
THORAX AND LUNGS:
 Symmetrical lung expansion; equal tactile fremitus noted.
 Resonant percussion across lung fields.
 No observed cough; clear breath sounds.
 Breathing is not labored.
ABDOMEN:
 Symmetrical in size and shape.
 Normoactive bowel sounds.
 No pain/ tenderness noted upon palpation.
focus assessment findings
BOWEL AND BLADDER:
 Light yellow, slightly aromatic (not foul odor)
 Normal frequency.
SKIN:
 No paleness noted.
 No visible signs of bleeding (bruising, petichae, etc.)
 Dry to touch, supple; no presence of lesions or scars.
 Skin turgor < 2 seconds

Hemoglobin (Hgb)
- Hemoglobin measures the amount of oxygen carrying protein in the blood. And determine the amount of hemoglobin in a person’s red blood cells (RBC’s).

Hematocrit (Hct)
- Indicates the percentage of red blood cells in a given volume of whole blood.

Red Blood Cell Count
- A red blood cell count is conducted to determine the presence of bleeding or anemia

White Blood Cell Count (WBC)
- A white blood cell count is ordered to determine if there is a presence of an allergy, inflammation or infection in a patient.

Lymphocyte Count (Lymph)
- A lymphocyte is a type of white blood cell in the responsible for immune system. This is to determine the presence of infection.

Eosinophil count
- To determine allergic reactions or presence of parasites.
Platelet -
This is the number of platelets in a given volume of blood. Both increases and decreases can point to abnormal conditions of excess bleeding or clotting.
Monocytes -
Indicates the presence of chronic inflammation, viral and parasitic infections, or tuberculosis.
Basophils
- Indicates hypersensitivity reactions to food or drugs.
Mean Corpuscular Volume (MCV)
- This is the volume of the average blood cell, and is the most useful of all the indices in determining the cause of anemia.
Mean Corpuscular Hemoglobin (MCH)
- A calculated value and is an expression of the average weight of haemoglobin per red blood cell. MCH, along with MCV can be helpful in determining the type of anemia present. This is an additional indice to the usual MCHC and MCV
Mean corpuscular Hemoglobin Concentration
(MCHC)
- Indicates the Hemoglobin in the average red blood cell and is a wright to volume relationship.
Neutrophils
- phagocytizes microorganisms. This test is done to determine the actual number of neutrophils in a measured amount of blood. This test indicates the risk of infection.
0 – 7 %
19 – 48 %
4.6 – 10.6 x 109/L
4.20 – 5.40 x 1012/L
36 – 47 %
11.6-15.5 G/DL
NORMAL VALUES
0.8
44.8
3.47
4.87
44.7
14.7
Nov. 24
1.8
38.9
4.87
4.87
43.4
14.1
Nov. 25
NORMAL VALUES
49.5
32.9
28.9
88
4.4
153
Nov. 24
55.4
32.5
29
89.2
2.7
102
Nov. 25
150 – 400 x 109/L
40 - 74%
32 – 35 g/dL
28 - 33.5 pg/cell
82 – 98 FL
0 – 2 %
3 – 9 %
0.5
1.2
(Low)
(Low)
(Low)
• Check for the specific test ordered by the doctor.
• Check for materials needed.
• Secure a laboratory request.
• Tell the client that there is no need to restrict foods and fluids.
• Explain the test and why it is needed.
• Explain to the patient that it is normal for the patient to feel pain and some discomforts while performing the procedure.
• Explain to the client that an amount of blood will be extracted from the brachial arm.
• Wipe with cotton balls and alcohol the site where insertion is done.
• Tell the patient when the needle will be inserted for them to get prepared.
• Ensure that the blood sample is not taken from a vein in the hand or arm with an intravenous line. Hemodilution with intravenous or plasma will lower the hematocrit value falsely.

• Apply pressure to the puncture site until bleeding stops.
• Assess the site for hematoma formation.
• Document the test performed
Blood is considered the essence of life because the uncontrolled loss of it can result to death. In diseases such as dengue, bleeding is a particular problem, because of the decrease in one blood element, platelets. Blood is a type of connective tissue, consisting of cells and cell fragments surrounded by a liquid matrix which circulates through the heart and blood vessels. The cells and cell fragments are formed elements and the liquid is plasma. Blood makes about 8% of total weight of the body.
BLOOD
FUNCTIONS OF BLOOD
• transports gases, nutrients, waste products, and hormones
• involve in regulation of homeostasis and the maintenance of PH, body temperature, fluid balance, and electrolyte levels
• protects against diseases and blood loss

PREVENTING BLOOD LOSS
When a blood vessel is damaged, blood can leak into other tissues and interfere with the normal tissue function or blood can be lost from the body. Small amounts of blood from the body can be tolerated but new blood must be produced to replace the loss blood. If large amounts of blood are lost, death can occur.
BLOOD CLOTTING
Platelet plugs alone are not sufficient to close large tears or cults in blood vessels. When a blood vessel is severely damaged, blood clotting or coagulation results in the formation of a clot. A clot is a network of threadlike protein fibers called fibrin, which traps blood cells, platelets and fluids.

The formation of a blood clot depends on a number of proteins found within plasma called clotting factors. A series of reactions results in which each clotting factor activates the next clotting factor in the series until the clotting factor prothrombin activator is formed. Prothrombin activator acts on an inactive clotting factor called prothrombin. Prothrombin is converted to its active form called thrombin. Thrombin converts the inactive clotting factor fibrinogen into its active form, fibrin. The fibrin threads form a network which traps blood cells and platelets and forms the clots.

CONTROL OF CLOT FORMATION
Without control, clotting would spread from the point of its initiation throughout the entire circulatory system. To prevent unwanted clotting, the blood contains several anticoagulants which prevent clotting factors from forming clots. Normally there are enough anticoagulants in the blood to prevent clot formation. At the injury site, however, the stimulation for activating clotting factors is very strong. So many clotting factors are activated that the anticoagulants no longer can prevent a clot from forming.
CLOT RETRACTION AND DISSOLUTION
After a clot has formed, it begins to condense into a denser compact structure by a process known as clot retraction. Serum, which is plasma without its clotting factors, is squeezed out of the clot during clot retraction. Consolidation of the clot pulls the edges of the damaged vessels together, helping the stop of the flow of blood, reducing the probability of infection and enhancing healing.
Predisposing Factors
:
Tropical Location
Precipitating Factors
:
Environmental Condition
Immunocompromised
Presence of dengue carrying mosquitos
Aedes egypti
bites the host injecting the virus
Redness
Itchiness
Virus incubates in the circulation for 3-14 days
Virus disseminates rapidly into the blood
Stimulation of WBC which includes B lymphocytes which produces and secretes Ig, monocytes/ macrophages and neutrophils

Anti-bodies attach to the viral antigens, and then the macrophages perform phagocytosis within the cells and dengue virus replicate in the cells
Diagnostic
• Increased production of WBC (Normal: 5000-10,000/mm3)
• Increased Lymphocytes
(Normal: 19-48%)
Diagnostic
• Decreased monocytes (Normal: 3-9%)

• Decreased neutrophils (Normal: 40-74%)
Recognition of dengue viral antigen on monocyte
Release of cytokines which consist of vasoactive agents such as interleukins, tumor necrosis factor, urokinase and platelet activating factor which stimulate WBCs and pyrogen release
Entry to spleen
Entry to Bone Marrow
DENGUE
SIGNS & SYMPTOMS
• Febrile
• Chills
• Headache
• Pain behind the eye
• Body ache
• Nausea and vomiting
• Swollen lymph nodes
Virus targets the liver and spleen parenchymal cells where infection produces apoptosis/cell death
Cellular direct destruction and infection of red bone marrow precursor cell
Hepatosplenomegaly
THROMBOCYTOPENIA
DENGUE
HEMORRHAGIC
FEVER
SIGNS & SYMPTOMS
• Joint pain
• Rashes

Diagnostic:
Hematology
• Decreased platelet
S/sx:
• Abdominal pain

Diagnostic: UTZ
• Minimal hepatosplenomegaly
Dengue is the
most common arthropod-borne viral (arboviral) illness in humans
. It is transmitted by mosquitoes of the genus Aedes, which are widely distributed in subtropical and tropical areas of the world. A small percentage of persons who have previously been infected by one dengue serotype develop bleeding and endothelial leak upon infection with another dengue serotype. This syndrome is termed dengue hemorrhagic fever. Dengue fever is typically a self-limiting disease with a mortality rate of less than 1%. When treated, dengue hemorrhagic fever has a mortality rate of 2-5%, but when left untreated, the mortality rate is as high as 50%.
INTUBATION PERIOD:
3 days to 14 days
PERIOD OF COMMUNICABILITY:
Unknown. Presumed to be on the 1st week of illness when virus is still present in the blood.
DENGUE GRADING
GRADING THE SEVERITY OF DENGUE FEVER:
Grade 1:
• fever
• non-specific constitutional symptoms such as anorexia, vomiting and abdominal pain
• absence of spontaneous bleeding
• positive tourniquet test
Grade 2:
• signs and symptoms of Grade 1: plus
• presence of spontaneous bleeding: mucocutaneous, gastrointestinal
Grade 3:
• signs and symptoms of Grade 2 with more severe bleeding: plus
• evidence of circulatory failure: cold, clammy skin, irritability, weak to compressible pulses, narrowing of pulse pressure to 20 mmHg or less, cold extremities, mental confusion
Grade 4:
• signs and symptoms of Grade 3, declared shock, massive bleeding, pulse less and arterial blood
• pressure = 1 mmHg (Dengue Syndrome/DS)
PETICHIAE
PREDISPOSING FACTORS
GEOGRAPHICAL AREA: Tropical
Being in tropical and subtropical areas increases your risk of exposure to the virus that causes dengue fever. Especially high-risk areas are Southeast Asia, the western Pacific islands, Latin America and the Caribbean.

PRECIPITATING FACTORS
ENVIRONMENTAL CONDITIONS
Aedes aegypti is extremely common in areas lacking piped water systems, and depend greatly on water storage containers to lay their eggs. Artificial or natural water containers are ideally larval habitats for this mosquito. This species has also been found in underground collections of water such as open or unsealed septic tanks, storm drains, wells, and water meters.
IMMUNOCOMPROMISED
An immunocompromised host is a patient who does not have the ability to respond normally to an infection due to an impaired or weakened immune system. This inability to fight infection can be caused by a number of conditions including illness and disease
PRESENCE OF MOSQUITOES CARRYING DENGUE VIRUS
This mosquito can bite people without being noticed because it approaches from behind and bites on the ankles and elbows. Aedes aegypti prefers biting people but it also bites dogs and other domestic animals, mostly mammals.
Fever
When the infected mosquito then bites another person, the virus enters that person's bloodstream. Since the virus is already in the body, fever is useful as a defense mechanism as the body's immune response can be strengthened at higher temperatures.
Chills
Chills (shivering) may occur at the beginning of an infection and are usually associated with a fever. Chills are caused by rapid muscle contraction and relaxation. They are the body's way of producing heat when it feels cold. Chills often predict the coming of a fever or an increase in the body's core temperature.
Headache
Muscles in your scalp, neck, and face tighten and contract, causing spasms and pain.
Pain behind the eye
As a result of headache, pain behind the eye occurs
Body Ache
Since the virus is in the bloodstream, this is a response from the immune system that is letting the body know that something is causing a disturbance.


Nausea and vomiting
Nausea and vomiting are symptoms of an underlying illness. Nausea is the sensation that the stomach wants to empty itself, while vomiting (emesis) or throwing up, is the act of forcible emptying of the stomach. The term "dry heaves" refers to an episode of vomiting where there is no food in the stomach to vomit, and only clear secretions are vomited
Swollen lymph nodes
Lymph nodes contain mainly lymphocytes, which produce proteins that capture and fight viruses and other microbes, and macrophages, which destroy and remove the captured material, swelling of the lymph nodes is an immune response of the body to infection.
Rashes
When an infected mosquito feeds on a person, it injects the dengue virus into the bloodstream. The virus infects nearby skin cells called keratinocytes, the most common cell type in the skin.
Joint pain
Due to low platelet count, the bone marrow will work harder to produce more platelets to compensate for the low count thus, resulting to joint pain.
Predisposing Factors
:
Tropical Location
Precipitating Factors
:
Environmental Condition
Immunocompromised
Presence of dengue carrying mosquitos
Aedes egypti
bites the host injecting the virus
Redness
Itchiness
Virus incubates in the circulation for 3-14 days
Virus disseminates rapidly into the blood
Stimulation of WBC which includes B lymphocytes which produces and secretes Ig, monocytes/ macrophages and neutrophils

Anti-bodies attach to the viral antigens, and then the macrophages perform phagocytosis within the cells and dengue virus replicate in the cells
Diagnostic
• Decreased monocytes (Normal: 3-9%)

Recognition of dengue viral antigen on monocyte
Release of cytokines which consist of vasoactive agents such as interleukins, tumor necrosis factor, urokinase and platelet activating factor which stimulate WBCs and pyrogen release
Entry to spleen
Entry to Bone Marrow
DENGUE
SIGNS & SYMPTOMS
• Febrile
• Chills
• Headache
• Pain behind the eye
• Body ache
• Nausea and vomiting
• Swollen lymph nodes
Cellular direct destruction and infection of red bone marrow precursor cell
THROMBOCYTOPENIA
Diagnostic:
Hematology
• Decreased platelet (11/25/2014)
ENVIRONMENTAL CONDITIONS
Near house or School --> Canals/ Stagnant water sites
IMMUNOCOMPROMISED
The patient is still young, and their immune system is still in the process of maturing.
PRESENCE OF MOSQUITOES CARRYING DENGUE VIRUS
The patient lives in an area where dengue carrying mosquitos are known to thrive.
Precipitating Factors
TROPICAL ENVIRONMENT
The Philippines is listed as a high risk site for dengue and is known for its tropical climate.
Predisposing Factors
CLASSIFICATION:
Mild - with slight fever (Noted in admitting assessment 11/24/ 2014), with or without petechial hemorrhage but epidemiologically related to typical cases usually discovered in the course of invest typical cases
GRADING THE SEVERITY OF DENGUE FEVER:
Grade 1:
• fever (11/24/2014)
• non-specific constitutional symptoms such as anorexia, vomiting and abdominal pain
• absence of spontaneous bleeding
• positive tourniquet test
Fever (Admission Assessment on 11/ 24/ 2014)
When the infected mosquito then bites another person, the virus enters that person's bloodstream. Since the virus is already in the body, fever is useful as a defence mechanism as the body's immune response can be strengthened at higher temperatures.
Headache
Muscles in your scalp, neck, and face tighten and contract, causing spasms and pain.
Body Ache
Since the virus is in the bloodstream, this is a response from the immune system that is letting the body know that something is causing a disturbance.
Name
Description
Purpose
Date Ordered
Client's
Response
Zinc Sulfate-E Zinc Syrup
It is a nutritional supplement that helps the body’s natural defense against damaging free radicals (antioxidant effect) and helps boost immune function.
It is a management for accute diarrhea. It helps to boost immune function and it helps to support optimum physical growth and development.
11/24/2014


Boost the immune system, prevents lower respiratory infections, promotes weight gain for eating disorder.
Paracetamol Syrup
for the symptomatic treatment of mild to moderate pain and fever.
the main uses of it is to relief pain and reduced fever
11/24/2014


Fever was relieved with use.
Hexetidine-Bactidol Gargle
Protects against formation of decay acids in mouth and teeth
It prevents the infections and provides relief to any minor injury requiring a germicide.
11/24/2014


The patient was free from mouth and throat infections.
Biobita
(food supplement)
Improves digestive health, appetite, and provides supplementary vitamins and minerals.
Helps to boost the appetite, immune system and it promotes good digestion.
11/24/2014

Patient adhered to treatment regimen and had a gradual increase in appetite.
• Check the physician’s orders, check the diagnosis and age of the patient
• Check the purpose of medication
• Check the nurses record for the time of last dose given
• Know the 10 Rs of Medication
Type
Description
Purpose
Date Ordered
Client's
Response
Diet as tolerated (DAT) Except for dark colored foods
Therapeutic nutrition in the treatment of the disease and disorder. It is indicated for clients who do not need dietary restrictions, the diet is adjusted to meet age specific needs throughout the life cycle. The only exception to this diet is dark colored foods.
To provide full nutritional needs...

Therapeutic nutrition in the treatment of the disease and disorder. It is indicated for clients who do not need dietary restrictions, the diet is adjusted to meet age specific needs throughout the life cycle. The only exception to this diet is dark colored foods.
11/24/2014
With the assistance of the mother and significant others, the patient adhered to this diet.
Type
Description
Purpose
Date Ordered
Client's
Response
Ambulation
Performs physical activity independently.
Increase client’s mobility, decrease the possibility of patient accidents and injuries. For normal functioning of the cardiovascular and musculoskeletal systems
11/24/2014
Maintains muscle strength, improves circulation, and increases independent activity. It contributes to decrease pulmonary complications.
NURSING RESPONSIBILITIES
• Assess the client’s response for the exercise.
• Evaluate needs for assistive devices that promotes activity and reduced dangerous falls and movements.
• Evaluate the safety of the immediate environment.
• Allow the client to perform the task at her own rate.
• Encourage for independent activity as able and safe.
NURSING RESPONSIBILITIES
• Explain the purpose of the diet.
• Assess for patient condition, how she respond to the diet
• Explain importance of compliance

S: Ø

O:
Risk Factors
- 152 platelet count (11/24)
- 102 (11/ 25)

Risk for bleeding related to a decrease in platelet count.
The most notable feature of Dengue is the drop in the patient’s platelet count. The platelets are important to stop bleeding (both for minute and major injuries). The lack of platelets poses the client at risk because there is not means to create the plug that travels to an injury when someone experiences injury.
OBJECTIVE
After 4 hours of nursing care, the patient will continue to remain free from bleeding.
- Monitored the patient for: bruising, epistaxis, abdominal pain, traces of blood in the urine, blood in urine and feces.

- Performed vital signs and basic physical assessments for the patient who is at risk for bleeding until assured the risk is past

- Assessed the clients daily activities and situations where the client may be at risk for bleeding.

- Advised the mother of the patient to use bactidol mouth wash in lieu of brushing as prescribed by the physician.

- Discussed with the patient’s mother alternatives in ADLs (i.e. supervising child when going to the bathroom, keeping sharps away, padding sharp table corners, only providing safe toys).

- Provided emotional support to the patient.


- Provided a safe (removed hazards), calm, and quiet environment.
- To identify need for immediate intervention



- To provide the data needed for early intervention.



- To provide a basis for individualized health teachings on the prevention of bleeding.

- To avoid a potential situation which may cause bleeding



- To enable the mother and the patient to avoid trauma-causing activities which may cause bleeding.



- To alleviate anxieties and fears regarding current condition.


- To promote rest and healing, and prevent accidents.

Intervention
Rationale
- Assessed continuously for signs of infection (i.e. vital signs, sudden fever, etc)

- Continuously protect the patient by practicing medical asepsis (i.e. washing hands before and after contact).

- Provide and encourage client to use prescribed bactidol mouth wash.

- continue to administer Paracetamol as prescribed.

- Provide skin care at appropriate intervals. Encourage hygiene, and range of motion exercises.

- Avoid unnecessary invasive procedures.


- Assist in the collection of blood specimens.

- Teach mother and patient the appropriate hand washing technique.

- Encourage to increase intake of fruits and vegetables (if tolerated, and not contraindicated).

- Encouraged patient to take zinc and biobita supplements.

- To determine the need for referral and/or additional and early intervention.

- carefully washing hands when caring for the patient and handling equipment prevents cross contamination between patients.

- to prevent potential sites of secondary infection (mouth and upper respiratory tract).

- To prevent recurring fever.

- To prevent infection related to prolonged laying/sitting, and poor hygiene.

- These provide reservoirs for infectious micro organisms.

- To allow for the continuous monitoring for infection and the provision of timely treatment if required.

- To empower client to take individual steps to protect the patient/ themselves.

- To boost immune system.


- To supplement nutritional needs required for healing.

Intervention
Rationale
- Obtain history of illness, age, presence of fever, and other factors.



- Monitor the vital signs for presence of hypotension/ orthostatic hypotension, tachycardia, and fever.




- Assess skin turgor and capillary refill.



- Strictly monitor the intake and the output.


- Emphasize increased fluid intake.
- Weigh client daily or as indicated.

- Start fluid replacement therapy as indicated.


- Monitor laboratory results i.e. Hemoglobin/hematocrit, coagulation studies

- It could aid in providing baseline data regarding client’s status and to be to correct factors contributing to client’s risk for fluid volume deficit.

- Presence of fever, hypotension and tachycardia are manifestations for hypovolemia or possible indication for dehydration.These are indicators for the hydration status of the client.


- It helps in monitoring how the kidney functions and to determine if fluid replacement therapy is needed.

- It helps in maintaining adequate circulatory volume in the body.


- It provides the current fluid status and adequacy of fluid replacement.

- The type and amount of fluid depend on the degree of dehydration.


- Dengue fever has potential for bleeding and these parameters are essential to determine if fluid replacement is effective or not.

Intervention
Rationale
- Assessed site of skin impairment and determine etiology

- Monitored client's skin care practices, noting type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing.

- Encouraged client to increase water intake.

- Used wet cotton ball on lips and encouraged patients mother to use mild moisturizer.

-Emphasized need to use mild, yet moisturizing, antibacterial soap.

- Educated and encouraged to eat well-balanced diet


- Monitor client's continence status


- Encourage client to ambulate.

- Educated client’s mother on skin assessment and to monitor for signs and symptoms of skin complications (such as redness, swelling, bruising, petichae, bleeding, and heat).

- Prior assessment of wound etiology is critical for proper identification of nursing interventions

- To Individualize plan according to client's skin condition, needs, and preferences.

- To restore original skin integrity.


- To prevent injury which can result from cracked skin.

- To prevent damage to the skin integument which may arise from harsh and skin-drying anti bacterial soaps.

- Vitamins and minerals from various fruits and vegatables may help improve skin integument.

- To eliminate other risk factors which may cause skin damage.

- To alleviate pressure and prevent other sources of skin damage.

- To empower the client to alert the nurse and other health care practitioner in the changes in clients’ status.

Intervention
Rationale
After four hours of nursing care, the patient showed no physical signs of bleeding and did not report abdominal pain. No blood was noted in the client’s urine and feces.
S:
Ø

O:
Risk Factors

- Low WBC count on
11/ 24/ 2014
(3.37 x 109/L)

Risk for infection related to low WBC count.
The reason for this slight to moderate decrease in WBC remains unknown, but one possible explanation is due to the migration of WBC to a site of infection during the early onset. Another possible explanation is due to immature immune system response due to age.
After 4 hours of nursing care, the client will maintain free from infection.
Objective
After four hours of nursing intervention, the client was still free from infection evidenced by the absence of fever.
S:
“Di siya mahilig uminom ng tubig”
the patient’s mother verbalized.

O:
Physical Assessment on 11/25
- cracked lips
- Delayed skin turgor >2 sec
- Delayed capillary refill >2 sec
- Dry skin.
- dark yellow urine.

Admission Assessment
- fever

Risk for fluid volume deficit related to personal habits.
One of the manifestations of dengue is fever, which can often lead to dehydration. With this patient, the fever was resolved with paracetamol, however, dehydration was a problem because of the patient’s personal habits with drinking water.
After four hours of nursing intervention, the patient will be able to:
- Replenish hydration status (as evidence by improved skin turgor and capillary refill).
The patient maintained normal vital signs and hydration status was improved as evidenced by capillary refill and skin turgor of <2 sec.

The patient was noted to increase fluids and comply with fluid replenishment measures. She increased her fluid intake as tolerated.
S:
Ø

O:
Physical Assessment on 11/25
- cracked lips
- Dry skin.
Risk for impaired skin integrity related to cracked lips and dry skin.
Dehydration can cause the skin to lose its initial integrity by being dry. The dryness of skin can further cause injury, which must be avoided in patients with dengue.
After four hours of nursing care, the patient will have improved skin integrity.
OBJECTIVE
After four hours of nursing intervention, the client remained free from skin injury.
• Continue to take Ezinc, once a day, with meals.
• Continue to take biobita, three times a day, in food or milk, to promote a healthy appetite.
• Gargle with bactidol, after meals, to prevent infection.
• Continue to take paracetamol, 4 times a day, after meals.
EDICATION: Ezinc, biobita , paracetamol, bactidol
XERCISE:
Walking every day for about 30 minutes to promote health lifestyle and prevent secondary infections. Encourage child to play with safe toys.
REATMENT:
IVF D5LRS1L x 18 gtts/ min only until end of confinement. Continue to avoid activities which may cause bleeding (i.e. using sharps, tripping/fall hazards, tooth brushing with hard bristles).
EALTH TEACHING: Drink plenty of water everyday, take nutritious food like vegetables and fruits.
IET: DAT (Diet as tolerated)
except for colored foods while the patient is still recuperating. Continue to monitor urine and stool for blood in the immediate two weeks following discharge. Continue to drink plenty of fluids to maintain hydration status, and a well-balanced diet (with fruits, vegetables, carbs, etc.) to promote healing.
UT PATIENT:
The patient should be back at the hospital after 1 week for her follow up check-up. The patient may return earlier, if symptoms worsen or bleeding becomes apparent.
OBJECTIVE

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