INTRODUCTION

Dengue is a mosquito-borne infection that in recent decades has

become a major international public health concern. Dengue is found in
tropical and sub-tropical regions around the world, predominantly in urban
and semi-urban areas.

Dengue haemorrhagic fever (DHF), a potentially lethal complication,

was first recognized in the 1950s during dengue epidemics in the Philippines
and Thailand. Today DHF affects most Asian countries and has become a
leading cause of hospitalization and death among children in the region.

There are four distinct, but closely related, viruses that cause dengue.
Recovery from infection by one provides lifelong immunity against that virus
but confers only partial and transient protection against subsequent infection
by the other three viruses. There is good evidence that sequential infection
increases the risk of developing DHF.

Dengue is a mosquito-borne infection that causes a severe flu-like

illness, and sometimes a potentially lethal complication called dengue
hemorrhagic fever. Global incidence of dengue has grown dramatically in
recent decades. About two fifths of the world's population is now at risk.
Dengue is found in tropical and sub-tropical climates worldwide, mostly in
urban and semi-urban areas. Dengue hemorrhagic fever is a leading cause of
serious illness and death among children in some Asian countries. There is
no specific treatment for dengue, but appropriate medical care frequently
saves the lives of patients with the more serious dengue hemorrhagic fever.
The only way to prevent dengue virus transmission is to combat the disease-
carrying mosquitoes.

The incidence of dengue has grown dramatically around the world in

recent decades. Some 2.5 billion people – two fifths of the world's population
– are now at risk from dengue. WHO currently estimates there may be 50
million dengue infections worldwide every year.

In 2007 alone, there were more than 890 000 reported cases of dengue in
the Americas, of which 26 000 cases were DHF.

The disease is now endemic in more than 100 countries in Africa, the
Americas, the Eastern Mediterranean, South-east Asia and the Western
Pacific. South-east Asia and the Western Pacific are the most seriously
affected. Before 1970 only nine countries had experienced DHF epidemics, a
number that had increased more than four-fold by 1995.

Not only is the number of cases increasing as the disease is spreading

to new areas, but explosive outbreaks are occurring. In 2007, Venezuela
reported over 80 000 cases, including more than 6 000 cases of DHF.

During epidemics of dengue, infection rates among those who have not been
previously exposed to the virus are often 40% to 50%, but can reach 80% to
90%.

An estimated 500 000 people with DHF require hospitalization each

year, a very large proportion of whom are children. About 2.5% of those
affected die.

Without proper treatment, DHF fatality rates can exceed 20%. Wider access
to medical care from health providers with knowledge about DHF - physicians
and nurses who recognize its symptoms and know how to treat its effects -
can reduce death rates to less than 1 %.
(http://www.who.int/mediacentre/factsheets/fs117/en/)

Here in the Philippines, There were 20,107 total number cases as of

2005. There were a total of 45,350 dengue cases and 416 deaths reported
as of 2007. A total of 337 reported dengue virus infections in 2009, the city
health office recorded only one death. Adding that most badly hit villages are
Lanao, Poblacion, Sudapin, Magsaysay and Singao. Based on reports
gathered from 58 hospitals and health centers in the region, dengue fever
cases rose to 550 cases from January 1 to the present compared to the 289
cases registered during the same period last year. This year (2010), Ifugao
recorded the highest number of dengue fever cases with 187 followed by
Mountain province with 97 with reported clustering of cases in Callutit,
Bontoc town. Kalinga reported only 27 cases while the conflict-stricken
province of Abra had 26 cases during the said period based on the CHD-CAR
report. Based on available data, DoH said 25,283 cases have been recorded
between January 1 and June 26 this year.
(http://www.flutrackers.com/forum/showthread.php?t=139659&page=2)

Objectives

Patient Centered

1. To provide quality and competent nursing care for faster recovery of

the patient.
2. To impart the health teachings to the client that would aid in the
understanding of the patient’s condition.
3. To ensure that the care received is within the standard quality nursing
care to improve the condition of the client.

Nurse Client Centered

1. To impart effective nursing care interventions and to meet the needs

of the patient that would aid in the recovery of the patient or
prevention of the further complications.
2. To impart proper health teachings to the family members especially
the mother who is the primary care provider of patient, so they may
practice independent caring of the patient’s condition.
 3. To help the family understand the nature of the patient’s condition and
enabled them to find ways to prevent further complications.

Student Centered

1. To promote nurse patient relationship that will result effective ways of

restoring the health of the patient.
2. To enhance our knowledge, skills, values and attitude to facilitate
effective and safe practice.
3. To be able to learn and be able to familiarized with the entity causative
agent and nature of the disease.
 NURSING HEALTH HISTORY

BIOGRAPHIC DATA

A female, 16 year old patient MGA was born on May 21, 1994 at
Malideg, Quirino, Ilocos Sur. Her father was JG, and her mother passed away
when she was 8 years old. Her father is a seaman and working abroad, for
now her aunt is the one taking good care of her. Their family was affiliated to
Roman Catholic.

REASONS FOR SEEKING HEALH CARE

Patient MGA was rushed at the nearest hospital in Ilocos Sur, having
the chief complaints of high centigrade fever and nose bleeding.

HISTORY OF THE PRESENT HELATH CONDITION

Five days prior to admission patient MGA complained of headache and

cough with whitish phlegm. The next day prior to admission the patient MGA
had fever with no other associated signs and symptoms such as diarrhea,
vomiting and colds, on that day, MGA took Tylenol but she was not relieved.
Few hours prior admission, when the above condition persisted associated
with profuse nose bleeding, she was being rushed and admitted at Dr.
Hipolito A. Resonable Memorial Hospital Inc. Ilocos Sur. She had two bouts of
ground coffee materials and a nasogastric tube was inserted also. She was
diagnosed of Dengue Hemorrhagic fever stage II after 1 day, the family
decided to transfer patient MGA to Lorma Medical Hospital for further
assessment and management.

PAST HEALTH HISTORY

 Patient MGA had no history of hospitalization. When she was young,
she was used on having simple cough and colds but not to the point of
seeking medical help. Patient MGA has already completed her immunization.

FAMILY HEALTH HISTORY

Patient MGA had no other family history aside from her father who has
hypertension.

LIFESTYLE AND HEALTH PRACTICES

Patient MGA loves to eat all kinds of vegetables and meat; she eats three
times a day with snacks at intervals. She has no known allergies to food or
any drugs. Her bowel movement is every other day. She walks in going to
school, it serves as an exercise to her, and she is also an active volleyball
player. They live in a concrete house with two rooms. Their water is supplied
by Nawasa and they are using water coming from the water pump as their
drinking water. They save water in a container because at times, there is no
enough water to supply their everyday needs. Their garbage is also collected
daily.

DEVELOPMENT LEVEL

According to Erickson Psychosocial Theory of Human Development,

Patient MGA is under Identity vs. role confusion, wherein in this chapter of
her life, she was able to established herself and having a place in the society.
She had developed herself confidence and be able to express herself in front
of other people. She was also on the process of establishing a good
relationship with the opposite sex, trust and fidelity to her friends as well as
to her family. She has a strong foundation of her personal values and beliefs.
She was already developed her identity because she was such a great girl,
she doesn’t easily give up on her goals, and there is determination in
everything she do. She knows when to stand on her own feet.

PHYSICAL ASSESSMENT

SKIN:

COLOR: light brown, tanned skin (vary according to race)

SOLES and PALMS: Lighter colored palms, soles

MOISTURE: skin normally dry

TEMPERATURE: normally warm

TEXTURE: smooth and soft

TURGOR: skin snaps back immediately

Neck is slightly hyper extended, without masses or asymmetry

HEAD AND NECK:

SCLERA: anicteric sclera,

CONJUNCTIVA: pink palpebral conjunctiva,

EYELIDS: puffy eyelids,

NARES: Oval, symmetric and no nasal discharge,

LIPS: light pink, dry and symmetric

Neck: slightly hyperextended,without masses or asymmetry

NECK ROM: Neck moves freely, without discomfort

THYROID GLAND: rises freely with swallowing

 THORAX AND LUNGS: Clear breath sounds

ABDOMEN: flat, Skin same color with the rest of the body, mild epigastric
area tenderness

BOWEL SOUNDS: Clicks or gurgling sounds occur irregularly and range

from 20 per minute

EXTREMITIES:

SYMMETRY: Symmetrical

SKIN COLOR: Same with the color of other parts of the body

HAIR DISTRIBUTION: Evenly distributed

SKIN TEMPERATURE: Warm to touch

PRESENCE OF LESION: No lesions
ROM: Able to move but with assistance

LYMPH NODES: no cervical lymphadenopathies

NEUROLOGY SYSTEM:

LEVEL OF CONSCIOUSNESS: Fully conscious, respond to questions

quickly perceptive of events

BEHAVIOR AND APPEARANCE: Makes eye contact with examiner,

hyperactive expresses feelings with response to the situation
 ANATOMY AND PHYSIOLOGY

BLOOD

Blood is considered the essence of life because the uncontrolled loss of

it can result to death. 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.

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

PLASMA

Plasma is a pale yellow fluid that accounts for over half of the total
blood volume. It consists of 92% water and 8% suspended or dissolved
substances such as proteins, ions, nutrients, gases, waste products, and
regulatory substances.
Plasma volume remains relatively constant. Normally, water intake
through the GIT closely matches water loss through the kidneys, lungs, GIT
and skin. The suspended and dissolved substances come from the liver,
kidneys, intestines, endocrine glands, and immune tissues as spleen.

FORMED ELEMENTS

CELL TYPE DESCRIPTION FUNCTION

Erythrocytes (RBC) Biconcave disk, no Transport oxygen and
nucleus, 7- carbon
8 micrometers in dioxide
diameter

Leukocytes (WBC): Spherical cell, nucleus Phagocytizes

Neutrophil with microorganism
two or more lobes
connected
by thin filaments,
cytoplasmic
granules stain a light
Basophil pink or
reddish purple, 12-15 Releases histamine,
micrometers in which
diameter promotes inflammation,
and
Spherical cell, nucleus, heparin which prevents
with clot
Eosinophil two indistinct lobes, formation
cytoplasmic granules
stain
blue-purple, 10-12 Releases chemical that
micrometers in reduce
diameter inflammation, attacks
Lymphocyte certain
Spherical cell, nucleus worm parasites
often
bilobed, cytoplasmic
granules Produces antibodies and
satin orange-red or other
 bright red, chemicals responsible
Monocyte 10-12 micrometers in for
diameter destroying
microorganisms,
Spherical cell with round responsible for allergic
nucleus, cytoplasm reactions, graft
forms a rejection,
thin ring around the tumor control, and
nucleus, regulation of immune
6-8 micrometers in system
diameter
Phagocytic cell in the
blood
leaves the circulatory
system
Spherical or irregular and becomes a
cell, macrophage
nucleus round or kidney which phagocytises
or bacteria,
horse-shoe shaped, dead cells, cell
contain fragments, and
more cytoplasm than debris within tissue
lymphocyte, 10-15
micrometers in diamete

Platelet Cell fragments Cell fragments

surrounded by surrounded by
a cell membrane and a cell membrane and
containing granules, 2-5 containing granules, 2-5
micrometers in micrometers in diameter
diameter

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. Normally the clotting factors are
inactive and do not cause clotting. Following injury however, the clotting
factors are activated to produce a clot. This is a complex process involving
chemical reactions, but it can be summarized in 3 main stages; the chemical
reactions can be stated in two ways: just as with platelets, the contact of
inactive clotting factors with exposed connective tissue can result in their
activation. Chemicals released from injured tissues can also cause activation
of clotting factors. After the initial clotting factors are activated, they in turn
activate other 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. The damaged vessel is repaired by the movement of
fibroblasts into damaged area and the formation of the new connective
tissue. In addition, epithelial cells around the wound divide and fill in the torn
area.

The clot is dissolved by a process called fibrinolysis. An inactive

plasma protein called plasminogen is converted to its active form, which is
called plasmin. Thrombin and other clotting factors activated during clot
formation, or tissue plasminogen activator released from surrounding
tissues, stimulate the conversion of plasminogen to plasmin. Over a period of
a few days the plasmin slowly breaks down the fibrin.
 PATHOPHYSIOLOGY

Modifiable factors: Modifiable

>gender factors:
>age
>antibodies to a dengue >tropical region
virus from previous infection
>lifestyle

Infected Aedes
Aegypti bites on
person who has
different type of
dengue virus

Secondary Activation of
infection from immune system
different type of
dengue virus

Generates an
antigen-
antibody
complex

Allows more
Release of cytokines
Cells will be virus
(immune system
infected particles to
signaling molecules)
enter
monocytes
 Vascular
permeability

Leakage of blood Bleedi

vessels ng

If not treated, it will

result in dengue shock
and to death
DIAGNOSTIC PROCEDURES:

HEMATOLOGY REPORT

PARAMTER NORMAL ACTUAL FINDINGS ANALYSIS

FINDINGS
White Blood Cells 5-10 x 10^g/L 4.8 x 10^g/L Decreased due to
inadequate
inflammatory
defenses to
suppress
infection and
humoral
immunity takes
place
Hemoglobin M: 13.0-18.0 g/dL 10.3 g/dL Decreased due to
poor
oxygen supply

Hematocrit 39-54 % 31% Decreased due to

poor
oxygen supply

Segmenters 0.60-0.70 0.57 Decreased;

indicate
low glucose level
in
 the blood
Lymphocytes 0.20-0.30 0.43 Increased due to
the
body’s increased
immune system
Platelet Count 150-450 x 10^g/L 95 x 10^g/dL hemolysis

Radiology Section

Examination: CHEST Pa

Interpretation:

Lungs are clear, heart is not enlarged, clear sulci and diaphragm, intact
bony thorax
 EVALUATION

Patient MGA was admitted to Lorma Medical Center on July 10, 2010 at
10:15 pm, having chief complaints of vomiting, fever and nose
bleeding.

She was diagnosed of Dengue Hemorrhagic Fever stage III. Intravenous fluid
was inserted to the patient into her left arm. Upon waiting for her laboratory
results, health care team exerted effort in rendering care for his condition.

Dependent, independent, and interdependent interventions were given

during the course of her confinement in order to relieve patient’s condition.
Dependent intervention includes the administration of his medications and
the daily check-ups done by his doctor.

Interdependent interventions involve the collaborative efforts with the

medical technologies that performed complete blood count and platelet
count; and the dietician who prescribe the appropriate for his condition. The
independent intervention include the taking and monitoring the vital signs,
performing tepid sponge bath if she has fever, providing well ventilated
environment, giving health teaching to the patient in regards to the
condition such as increasing her fluid intake, proper hygiene, and to eat
nutritious foods.

During the interaction to the patient and to her family, rapport was
established and was able to organize efficient care. As the group performed
the study our objective was achieve in educating ourselves in enhancing
knowledge regarding dengue hemorrhagic fever.

The group also imparted some health teachings such as e proper

prevention of dengue, by eliminate mosquito breeding sites and reduce the
risk of dengue by checking around their house and to empty buckets, cans,
flower pots and other items that may contain water. Use insect repellents
and spray insecticides if there are mosquitoes in the vicinity. We also
stressed the importance of cleanliness. We also advised the aunt to make
sure that her children get adequate nutrition to increase resistance from any
diseases. We also instructed the patient to have adequate rest, and drink
plenty of fluids. Patient MGA was transferred from ICU to the ward on July 13,
2010.