dengue case
DESCRIPTION
CASE STUDY OF DENGUETRANSCRIPT
Saint Michael’s College of LagunaSchool of Nursing & midwifery
Old National Road, Platero Biñan Laguna
In partial fulfillment in our Related Learning Experience
A case study on
Dengue Hemorrhagic
Fever
Ms. Edith Vizarra RN, ManClinical Instructor
Submitted By AÑABIEZA, Babyrlene P.
Date of Rotation
July 19-21, 26-28, 2010
INTRODUCTION
GOAL
To be knowledgeable about the nature of Dengue Fever Syndrome,
management and treatment to be able to render effective nursing
care to the client.
To be knowledgeable on how to prevent the disease
To know the treatment and how to apply it
To know the diagnostic exam
We live in our world today where everything seems to be in a fast face.
As it is, we cannot deny that things change over or in a certain period of
time. New technologies were being invented, clothes for fashion, jewelries,
luxuries mode of entertainment, etc. It’s just like having a new mode of
socialization, cultures, beliefs, perceptions, adaptation to life and environment.
With all of these, one aspect of human being which are greatly affected and the
one which we have to be most concern of would be in the side of our heath and
well being.
In the Philippines there are many diseases illness arising because of
environmental changes that may be caused by human activities and
geographical conditions. It is considered as one of the tropical country and so
disease can spread through out the country.
One example of these is disease is what we called Dengue Fever and
dengue Hemorrhagic Fever (DHF). It is considered as one of the acute febrile
diseases caused by one of the four closely related virus serotype of the genus
flavivirus. It can be transmitted by Aedes Aegypti mosquito to humans usually
attacking during the day. One will experience onset of fever, severe headaches,
muscle and joint pains which will give name to Breakbone Fever or Bonecrusher.
There are also rashes characterized by bright red petechaie commonly seen on
the lowers limbs and on the chest. There may also be gastritis associated to
abdominal pain, nausea, vomiting, or diarrhea. Proper attention of health care
provider should be given including good assessment, early detection or diagnosis
and medications which are essential for total interference of prevention.
Causative agentIt is caused by four antigenically related but distinct serotypes of the dengue virus DEN-1, DEN-2, DEN-3 and DEN-4.
Mode of transmissionA strain of Arbovirus caused Dengue Hemorrhagic Fever and transmitted by the Aedes aegypti mosquito.
Characteristics of an Aedes aegypti mosquito: 1. Daybiting 2. Low-flying 4. In urban area
Incubation PeriodThere is an incubation period of 3-14 days (usually about 4-7).
Signs and Symptoms 1. Rapid deterioration Deterioration occurs after 2–5 days of the typical symptoms of dengue fever 2. Irritability Associated with rapid deterioration 3. Restlessness Associated with rapid deterioration 4. Low blood pressure Related to hemorrhage 5. Weak and rapid pulse Related to hemorrhage 6. Petechial rash Related to hemorrhage
Stages of Dengue Hemorrhagic Fever
* Grade I: fever + Herman's sign (flushes and redness of skin with lighter color at the center of the rash) * Grade II: Grade I symptoms + bleeding (epistaxis or nosebleeding, gingival bleeding, hematemesis or upper gastrointestinal bleeding; e.g: vomiting of blood), and melena or dark stool. * Grade III: Grade II + Circulatory Collapse (hypotension, cold clammy skin and weak pulse) * Grade IV: Grade III + Shock.
Diagnostic Tests 1. Complete blood count to detect elevated white blood cell count, decreased platelet count (thrombocytopenia), and increased hematocrit. 2. Blood test for antibodies. 3. Ask the client about a history of travel to tropical or subtropical areas.
Complications list for Dengue fever:
The list of complications that have been mentioned in various sources for Dengue fever includes:
Fatigue ,Tiredness ,Dengue hemorrhagic fever - this can cause several serious complications(Bleeding ,Shock, Very low blood pressure ,Death)
Medical Management
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).
Management Do not give Aspirin because it contains at antiplatelet property which prmotes bleeding.Treatment is solely supportive and includes: * Fluids. * Analgesics (not aspirin) for fever and muscles aches. * Replacement of plasma or plasma expanders.
Nursing Management Dengue is a self-limited illness but recovery might take a few weeks.
Independent: Close monitoring of vital signs in critical period (between days 2 to day 7
of fever) is critical. Increased oral fluid intake is recommended to prevent dehydration. Treatment is purely concerned with relief of the symptoms (symptomatic).
Dependent: Because dengue is caused by a virus, there is no specific medicine or
antibiotic to treat it. Aspirin and nonsteroidal anti-inflammatory drugs should be avoided as
these drugs may worsen the bleeding tendency associated with some of these infections.
Acetaminophen (Tylenol) and codeine may be given for severe headache and for the joint and muscle pain (myalgia).
(DHF) Oxygen and sedatives may be administered.
Collaborative: A platelet transfusion is indicated in rare cases if the platelet level drops
significantly (below 20,000) or if there are significant bleeding. The presence of melena or blood in the stool may indicate internal
gastrointestinal bleeding requiring platelet and/or red blood cell transfusion.
Prevention of Dengue hemorrhagic fever:
Methods of prevention of Dengue hemorrhagic fever mentioned in various sources includes those listed below. This prevention information is gathered from various sources, and may be inaccurate or incomplete. None of these methods guarantee prevention of Dengue hemorrhagic fever.
See prevention of dengue Avoid mosquito bites Mosquito repellant Protective clothing Window screens
Remove water-filled mosquito breeding areas Dengue vaccine - not yet available but being researched. See also prevention of mosquito bites See also prevention of mosquito-borne diseas
PATIENT’S PROFILE
Name: Miss X
Age: 22
Gender: Female
Address: 141 Sitio Salvacion Tunasan Muntinlupa City
Date of Birth: September 9, 1987
Place of Birth: Muntinlupa City
Nationality: Filipino
Religion: Roman Catholic
Civil Status: Single
Occupation: Toshiba Employee
Date of Admission:
Time of admission:
Physician:
Place of Admission: Biñan Doctors Hospital
Admitting Diagnosis: Dengue Fever Syndrome
A.1 CHIEF COMPLAIN
Fever
Patients Hx
The patient complains of abdominal pain, headache, fever and general
flushing of skin with on and off vomiting.
a.2 PRESENT ILLNESS
Four days prior to admission, the patient had an intermittent fever
associated with abdominal pain, headache, and general flushing of the
skin with on and off vomiting. A few hours prior to admission still the above
sign and symptoms remain but already have (-) vomiting with
accompanying chills and was diagnosed with Dengue fever Syndrome.
a.3 PAST MEDICAL YEARS
It was according to the patient that she wasn't been hospitalized yet not
until when she was diagnosed with Dengue Fever Syndrome. Before that
diagnosis, she was already experiencing fever and her mom gives her a
Paracetamol for remedy.
a.4 FAMILY HISTORY
According to her grandmother the only disease that the family has
genetically is Diabetes Mellitus and no other diseases noted.
a.5 SOCIAL HISTORY
Miss X is the daughter of Mr. and Mrs. SJ. CJS is currently working at
Toshiba as an employee at Sta. Rosa Citys.
Her father works as a seaman while his mother is a housewife; her
grandmother is also living with them. Hence, her grandmother and her
mother were the ones responsible in all the household chores.
According to Miss X, she eats vegetables and fish instead she prefers
eating hotdogs. Furthermore she has no vices except for computer
games. After working hours, she goes directly at home to relax.
a.6 ENVIRONMENTAL HISTORY
According to the patient the environment that the family has an open
drainage, wherein big rats and cockroaches can be seen. The house is
cleaned by her mother and grandmother. It was described by the patient that
there are parts of their house that is deprived from light.
C. HISTORY OF ILLNESS
During the mid of, Miss X, started experiencing fever that persist only at night.
As a remedy her mom gave her Paracetamol to lower her body temperature.
Except from fever she’s also experiencing abdominal pain, headache and
general flushing of the skin with on and off vomiting.
As the above signs and symptoms persists, her parent decided to bring
her to the hospital.
Upon the physical assessment and after several diagnostic procedures
that the patient had undergone, she was diagnosed with Dengue Fever
Syndrome (DFS) and was admitted under the service of Dr. Olivares.
THEORETICAL FRAMEWORK
Miss X, , was diagnosed of having Dengue Fever Syndrome (DFS).At the
clinical check-up, the physician was able to identify some clinical signs of it and
was referred to Dr. Olivares. The case of Miss X can be correlated with the
theory of Florence Nightingale .
Application Theory:
The case of CJS can be correlated with the theory of Nightingale wherein,
the environment of the patient is a factor leading to recovery. Having a clean,
well ventilated and quite environment is important in. With a nurturing
environment, the body could repair itself.
PHYSICAL ASSESSMENT (Normal Findings Actual Findings Rationale)
Area Assessed Method Used Normal Findings Actual Findings RationaleSKINColor and pigmentationLesionsTextureMoistureTemperatureMobility and turgor
NAILSNail bed colorShapeLesionsThicknesscapillary refill
Inspection
InspectionPalpationPalpationPalpationPalpation
InspectionInspectionInspectionPalpationPalpation
Light to deep brown
No lesions, scars or inflammationSmoothMoistThe skin springs back to its previous state after being pinched
PinkConvexNo inflammation ofthe skin around the nailFirm
General flushing
No lesions, but presence of scars SmoothMoistThe skin springs backto its previous stateafter being pinchedPaleConvexNo inflammation of theskin around the nailFirmNormal capillary refill
Decrease WBCin the bodyNormalNormalNormalNormalNormal
Decrease RBCin the bodyNormalNormalNormalNormal (less than 3secs)
HEADSizeSymmetry
InspectionInspection
Proportion to the bodyand the skull isrounded and smooth
Proportion to the bodyand the skull is
NormalNormal
HAIRColorTextureOther findings
SCALPDistribution of hairLesionsOther findings
FACESkin colorTextureFacial movement
EYESExternal structureEyebrowsEyelashesEyelids
EARSColor
InspectionInspectionInspection
InspectionInspectionInspection
InspectionInspectionInspection
InspectionInspectionInspectionInspection
Inspection
Symmetrical
BlackCurly hair, straightNo nits/lice present
Evenly distributedNo inflammation,lumps or masses
Light to deep brownSmoothSymmetric facialmovement
Evenly distributedEvenly distributed,Evenly distributed, curved outward
Same as facial colorSymmetrical at the
roundedand smoothSymmetricalNo nits/lice present
No inflammation, lumpsor masses
PinkishSymmetric facialSymmetric facialmovement
Pink conjunctivaEvenly distributedEvenly distributed
Symmetric to headNo discharges and
NormalNormalNormal
NormalNormalNormal
Due to feverNormalNormal
NormalNormalNormal
SymmetryShape and size
NOSEColorShapeDischarges
MOUTH LipsSymmetryMoisture
TONGUEPositionColorTextureMobilityLesions
NECKPositionSymmetry
InspectionInspection
InspectionInspectionInspection
InspectionInspectionInspection
InspectionInspectionInspectionInspectionInspection
InspectionInspection
level of the eyescornerSymmetric to headNo discharges andinflammationSame as facial color
Same with facial colorSymmetricNo discharges
SymmetricPinkMoist
Positioned at thecenter can movefreelyDull redSmoothCan move freelyNo lesions orinflammation
Head centeredSymmetricalSmooth movements
inflammationNormal
Same with facial colorSymmetricNo discharges
SymmetricPinkDry
Central positionDull redSmoothCan move freelyNo lesions orinflammation
Head centeredSymmetrical
NormalNormalNormal
NormalNormalNormal
NormalNormalD/t poornutrition
NormalNormalNormalNormalNormal
Normal
Range of movements
UPPER AND LOWEREXTREMITIESSizeSymmetryDistribution of hairSkin colorLesions
Temperature
InspectionPalpation
InspectionInspectionInspectionInspectionInspection
Inspection
without discomfortSymmetric and atmidline position
Equal sizeSymmetricalEvenly distributedLight to deep brownNo lesions,deformities orinflammation
Normal
Smooth movementswithout discomfortSymmetric and atmidline position
Equal sizeSymmetricalEvenly distributedLight to deep brownNo lesions,deformities orinflammation
Normal
NormalNormalNormal
NormalNormalNormalNormalDue todisease
Normal
GORDON’S 11 FUNCTIONAL HEALTH PATTERN
FUNCTION BEFORE
HOSPITALIZATIONDURING
HOSPITALIZATIONINTERPRETATION
Nutrition Eats 3x a day She loves to eat
bread & processed foods such as hotdog, tocino, longanisa, and others.
She doesn’t eat vegetables and fish
Seldom drinks water
Mostly eat bread
This time she frequently drinks
water
The Doctor ordered DAT diet to the patient except dark colored food
To replace fluid loss
Elimination She is able to urinate & defecate normally everyday by herself
She doesn’t have any problem on her elimination
Defecates usually early in the morning before going to school
She can still urinate & defecate by herself even without an assistance
Her condition doesn’t affected her elimination pattern
Sleeping Has a regular sleeping pattern
Normal sleep is 6-8 hrs. per day but she naps for 1-2 hrs in the afternoon
Disturbed sleeping pattern
Due to adherence to time of medication & vital signs monitoring
Cognitive-Perceptual
Pattern
Has a normal cognitive perception
Can comprehend well
She responds appropriately to
She is responsive & can communicate well
Portraying cooperativeness
verbal & physical stimuli
Self- Perception-Self concept
Perceived herself as a good friend, brother & DAughter.
This times he perceives herself as an approachable person
Due to her ability to establish good rapport to other people
Role Relationship Pattern
He was able to do his responsibilities as a son & brother
This time his role as a patient is not fully met
Due to his condition, she is not aware of performing her real role in this field.
Sexuality-Reproductive
Pattern
She thinks of having a boyfriend & getting married.
Same Due to her age, it is still not her priority in life
Coping Stress & Tolerance Pattern
She doesn’t fully identifies her stressors.
Same At her age, she still has a playful mind & she doesn’t mind the stressors in life.
Activity-Exercise Pattern
Her daily routine on playing computer. Her daily activities were limited in waking up in the morning to attend his class & after that going to computer shop.
She interacts with his grandmother & other people around her
Cooperates well to the doctor & nurses.
She only focuses on simple things.
Value-Belief Pattern
She is a Catholic Due to their culture preferences & parent’s influence
Health Perception – Health
Management Pattern
She perceived her health in the state of good condition
She thinks that she is not healthy
Due to her illness
Anatomy And Physilology
The Circulatory SystemThe tiniest of the blood vessels, and the place where the exchange of nutrients and waste products takes place between the blood and the tissue fluids, is the capillaries.
The Lymphatic System
An often overlooked part of the circulatory system is the lymphatic system. As blood passes through the capillaries, some of the fluid diffuses into the surrounding tissues. One function of the lymphatic system is to collect and recycle this fluid (called lymph). Lymph passes from capillaries to lymph vessels and flows through lymph nodes that are located along the course of these vessels. Cells of the lymph nodes phagocytize, or ingest, impurities such as bacteria, old red blood cells, and toxic and cellular waste. Finally, lymph flows into the thoracic duct, a large vessel that runs parallel to the spinal column, or into the right lymphatic duct, both of which transport the lymph back into veins of the shoulder areas where is mixes with blood and is returned to the heart. All lymph vessels contain one-way valves, like the veins, to prevent backflow.
The tissues of the lymphatic system include the spleen. The spleen serves as a reservoir for blood, releasing additional blood into the circulatory system as needed. It is also involved with destruction of old cells and other substances by phagocytosis. The lymphatic system is also responsible for collecting nutrients that the digestive system has extracted from our foods, and is a very important part of the immune system. We will cover the lymphatic system in detail in the lesson on the immune system.
Babyrlene P. Añabieza Miss Edith Vizcarra RN, MANBSN 4A Clinical Instructor
“Journal of Ultrastructural studies on dengue virus type 2 infection of cultured human monocytes”
Background
Early interaction of dengue virus and monocyte/macrophages could be an important feature for virus dissemination after its initial entry via the mosquito vector. Since ultrastructural analysis of this interaction has not been reported, dengue type 2 (DEN2) virus-infected human monocyte cultures were studied at 1, 2, 4 and 6 hours after infection.
Results
Typical dengue particles and fuzzy coated viral particles were 35 to 42 nm and 74 to 85 nm respectively. Viruses were engulfed by phagocytosis and macropicnocytosis leading to huge vacuoles and phagosomes inside the monocytes. Interaction of monocytes with DEN2 virus induced apoptosis, characterized by nuclear condensation and fragmentation, cellular shrinkage, blebbing and budding phenomena and phagocytosis of apoptotic cells by neighboring monocytes. This finding was confirmed by TUNEL. Ultrastructural features associated to DEN2 virus replication were not observed.
Conclusion
These data suggest that clearance of the virus by monocytes and cellular death are the main features during the initial interaction of DEN2 virus and monocytes and this could be important in the rapid elimination of the virus after infection by mosquito vector.
Reference: Halstead SB, O'Rourke EJ, Allinson AC: Dengue virus and mononuclear phagocytes. II. Identity of blood and tissue leukocytes supporting in vitro infection.
Brand name/ Generic name
Classification Action Indication Adverse Effect Contraindication Nursing consideration
Acetaminophen(Paracetamol)
Nonopoiod analgesics and anti pyretics
Produce analgesia by blocking pain impulses by inhibitinfg synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation.
Symptomatic relief of pain and fever. Relief of headache, toothachge, back pain, dysmenorrheal,myalgias,neuralgias, etc. Analgesics and anti pyretic for patients hypersensitive to aspirin
Rash, nausea, vomiting, blood dyscrasias , anemia, analgesic nephropathy , nephrotoxicity , hypersensitivity reactions
Hypersensitivity. Patients
Patients with alcoholic liver disease. Impaired liver or kidney function
Brand name/ Generic name
Classification Action Indication Adverse Effect Contraindication Nursing consideration
Generic Name:Ciprofloxacin
Brand Name: Pharex Ciprofloxacin
Classification: Anti-infectives
. Inhibits bacterial DNA gyrase thus preventing replication in susceptible bacteria
> Infections of the resp. tract, middle ear,paranasal sinuses, eyes, kidneys, urinary tract
> Drugs that inhibit peristalsis. Infants and children, growing adolescents. Pregnancy and lactation
> Drugs that inhibit peristalsis. Infants and children, growing adolescents. Pregnancy and lactation
>Assess pt for previous sensitivity reaction>Assess pt for any s/s of infection before & during treatment>Assess for adverse reactions >assess pt. & family’s knowledge of drug therapy
Brand name/ Generic name
Classification Action Indication Adverse Effect Contraindication Nursing consideration
Generic Name:
Brand Name:
Classification .
ASSESSMENT NURSINGDIAGNOSIS
SCIENTIFICEXPLAINATION
PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:“Masakit ang tiyan ko” as verbalized by the patient.
Objective:>C pain scale of 7/10>grimace noted>irritable>weakness notedCharacteristic: Stabbing, shooting painOnset: “pasumpong sumpong po eh” as verbalized by patientLocation: No exact Location” sa buong tiyan poh as verbalizationDuration: 2-3 minutesExacerbations: Gets worst when pressure is applied in the
Acute pain related to inflammatory response as evidenced by verbalization of patient “ masakit po tiyan ko” pain scale of 7/10, grimace & irritability
.This is due to Entry of pathogens in circulation leading to release of anti-inflammatory mediators and as a vascular response it cause increase in capillary permeability leading to hyperemia and cellular exudation, swelling and pain
With in 30 minutes and for the whole period of duty the patient will be free from pain from 7/10 to 1/10
Independent:
>monitor v/s
>Instructed to deep breathing excersise>Encourage to have Diversional activities like watching t.v.>Place patient in a comfortable position>Encourage to have adequate bed rest>Provided therapeutic touch
Dependent:
>Administered Ranitidine as ordered
> To determine alteration in present condition>Helps relieving pain
>To divert attention from and reduce pain felt
>To provide comfort
>To have energy
> Helps in relieving pain
Goal Partially met,After 30 hour of nursing care the patient was able to reduced pain felt from 7/10 to 5/10 as evidenced verbalization of the patient
stomachRadiation: Radiates in the whole abdomenRelief: “ kapag iniipit ko tiyan ko nwawala minsan sakit”
>skinwarm to touch >flushed skin>temp. 38>c dry lips
Elevated body temperature related to presence of infection or inflammatory response as evidenced by temp- 38, flushed and warm skin to touch
Entry of pathogens in the systemic circulation leading to regulation of toxins in the body and release of pyrogens causig stimulation of hypothalamus leading to increase of thermoregulation and increase in body tempertature
Within 30-1 hour of nursing intervention & for the whole period of duty the patient temperature will decrease with in the normal range from 38 to 37 C
Independent:
> Rendered sponge bath
>Encourage to increase oral fluid intake>Promote Surface cooling, loosen clothing, and cool environment>Encouraged to have adequate bed restDependent:>Administer Paracetamol as ordered
>To promote Surface cooling and allow heat to release >To replace fluid loss due to body heat>To release heat through evaporation and conduction
>To reduce metabolic demand and regain energy
>To decrease temperature and support circulating volume and tissue perfusion
Goal met,After 45 minutes of nursing care, the patient temperature decrease from 38C to 36.8 as evidenced by normal temp and absence of flushing and cool skin
Exam Result Normal Values Interpretation
WBC 12.8 5 – 10 x 10 ^/LIncrease WBC indicates
Leukocytosis can be a sign of infection.
Segmenters 0.90 0.60 -0.70
Increase Segmenters indicates the presence of an acute bacterial infection or some inflammation
going on inside the body
Lymphocytes 0.08 0.20 – 0.40Decrease Lymphocytes indicates
can be sign of infection.
Hgb 116 140 -180 Normal
Hct 0.35 0.40 – 0.54 Normal
Platelets Count 110 150 – 450 x 10 ^/ L Due to presence of bleeding
PATHOPHYSIOLOGY
↓
Bite of aedes aegypti mosquito carrying a virus↓
Virus goes into the circulation↓
Infects cells & generate cellular response↓
Initiates destruction of the platelet↓
↑ Potential for hemorrhage↓
Stimulates intense inflammatory response ▼ ▼Release of exogenous pyrogens body releases anti- ↓ inflammatory mediators↑ WBC (Neutrophils & Macrophages) (Histatin, Kinins) ↓ ↓Release of endogenous pyrogens Vascular response ↓ ↓ Reset of hypothalamic thermostat Redness & Heat ↓ ↓ Fever Headache, Vomiting ▼ ▼ Epistaxis, Abdominal pain Muscle contract Blood vessels Circulatory Collapse Shock To produce construct to ↓ Additional heat prevent loss of body heat DEATH ↓ ↓SHIVERING CHILLS
Non- predisposing Factor:- Age:- Female
Predisposing Factor:-Immuno compromised - Environment
Discharge Planning
A. Patient's Name:> C.J.S a thirteen year-old male patient, who was diagnosed with Dengue Hemorrhagic Fever.
B. Diet:> Encourage nutritious foods like vegetables, meat and fruits.
C. Medications:> Give acetaminophen in case the temperatures increases.> Give oresol to replace fluid in the body.
D. Treatment:> Increased oral fluid intake.
E. Health Teaching:> 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.> U- Use insecticides at home to kill or reduce mosquito.> E- Encourage the family of the patient to clean the surroundings to destroy the
breeding places of mosquito.