Universidad De Manila

(Formerly City College Manila)

A. J. Villegas St., Mehan Gardens, Ermita, Manila

DENGUE FEVER SYNDROME

In Partial Fulfillment of the Requirements

in the subject Nursing Leadership and
Management-Related Learning
Experience (RLE) Pedia Ward

SUBMITTED BY:
Marcial, Christina S.
NR-41 Group 5

SUBMITTED TO:
Mr. Ronal S. Gamiao, RN
 Clinical Instructor
I. INTRODUCTION

Things change over or in a certain period of time like new technologies that were
invented such as clothes for fashion, jewelries, luxuries mode of entertainment and many more
stuffs. Just like having a different way of socialization, cultures, beliefs, perceptions, adaptation
to life and environment. With all of these, one aspect of human being is greatly affected and the
one which we have to be most concern of would be is our heath and well being.

As people continue to discover and invent things, the discovery of illnesses and diseases
also increases, and these diseases become severe. In the Philippines there are many diseases
and 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, family Flaviviridae, which 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.

The WHO says some 2.5 billion people, two fifths of the world's population, are now at
risk from dengue and estimates that there may be 50 million cases of dengue infection
worldwide every year. The disease is now endemic in more than 100 countries.
 The incidence of dengue has grown dramatically around the world in recent decades.
Some 2.5 billion people, which is about 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.

Global warming may have contributed to a 43 percent rise in the number of dengue
cases in the Philippines for the first half of the year. The biggest increase in the country was
seen in Metro Manila, where there was an almost 200 percent increase.

According to government figures 15,061 cases of the disease in the Philippines were
reported in the first six months of the year. The increase in the number of dengue cases may be
attributed to the constantly changing climate brought by global warming as well as congestion
in urban areas.

The patient, Mr. X was diagnosed with Dengue Fever Syndrome. This case study was
chosen because it can expand the learning and knowledge of those persons inclined in the
medical field and since recently, there were a lot of people having this disease and it even
becomes one of the headlines of different newspapers.

The implication of this case study to the nursing education is that it can be of great help
to the student nurses to become efficient nurses someday by being effective from the
assessment until the evaluation process of the case. We also resolutely believe that this study
aims to become informative to us, student nurses, who opt for sufficient and effective learning.

As part of the related learning experiences, this case study can give sufficient
background about the cause and effect of Dengue Fever Syndrome, along with its practical and
effective interventions and management that would somehow suffice the condition of the
patient. Moreover, in the field of nursing research, this study is beneficial in giving future
nurses significant information with regards to the said
II. CLINICAL SUMMARY

General Data

Name: Patient X

Age: 12 years old

Gender: Male

Hospital Number: 2241206

Address: Vito Cruz, Manila

Date of Birth: June 4, 1998

Place of Birth: Manila

Nationality: Filipino

Religion: Roman Catholic

Civil Status: Single

Occupation: N/A (Student 1st year High School)

Date of Admission: November 19, 2010

Resident in-charge: Dr. Manaligid/ Dela Cruz/ Robles

Clerks in-charge: JI Tabucan/ Valdez/ Valenzuela/ Yu

Admitting Diagnosis: Dengue Fever Syndrome

Chief Complain

This is a case of a 12 year old male who was brought in due to fever.

History of Present Illness

2 days prior to consult patient was noted to have a fever of 40oC. There was no
associated cough, no colds, no abdominal pain and no nose bleeding. The patient was self-
medicated with paracetamol (12 mkd) every 4 hours which was provided temporarily to relieve
the symptom.

1 day prior to consult, there was persistent symptom which prompted consult to a
private physician where initial CBC was requested and it was revealed in the result that the
patient’s hemoglobin was 13.7, hematocrit was 38, platelet was 141 and the white blood cell is
6.

The patient was diagnosed with Dengue Fever Syndrome and referred to Ospital ng
Maynila Memorial Medical Center, thus have admitted.

Past Medical History

 According to the patient, he was never been hospitalized before due to any disease until
now that he was diagnosed with Dengue Fever Syndrome.

Familial History

There was a family history of hypertension and bronchial asthma on the patient’s
mother side wherein the patient’s uncle has bronchial asthma while his grandmother was the
one who has hypertension. There was no history of pulmonary tuberculosis and diabetes
mellitus in the family.

Gordon’s Functional Health Pattern

FUNCTION BEFORE DURING INTERPRETATION
HOSPITALIZATION HOSPITALIZATION
Nutrition • Eats 3x a day • Mostly eat bread • The Doctor
ordered DAT diet to
• He loves to eat
the patient except
bread & processed
dark colored food
foods such as hotdog,
tocino, longanisa,
and others.

• He doesn’t eat
much vegetables and • This time he
• To replace fluid
fish frequently drinks
loss
• Seldom drinks water water

Elimination • He is able to urinate • He can still urinate & • His condition

& defecate normally defecate but needs affected his
 everyday by himself assistance elimination pattern

• He doesn’t have any • For 2 days he was

problem on his not able to defecate
elimination
Sleeping • Has a regular • Most of the time he • Due to adherence to
sleeping pattern was asleep and it was time of medication &
sometimes vital signs
• Normal sleep is 6-8
interrupted monitoring
hrs. per day but he
naps for 1-2 hrs in the
afternoon
Cognitive- • Has a normal • He is responsive & • Portraying
Perceptual cognitive perception can communicate cooperativeness
Pattern well
• Can comprehend well

• He responds
appropriately to
verbal & physical
stimuli
Self- • Perceived himself as • This time he • He views himself as
Perception- a good friend, brother perceives himself as someone that needs
Self concept & son. someone who needs to be taken care of at
care of his family the moment.
Role •He was able to do his • his role as a patient is • Due to his condition,
Relationship responsibilities as a not fully met he cannot perform
Pattern son & brother his responsibilities
Sexuality- • He doesn’t think of • Same • Due to his youthful
Reproductive the things like having mind, it is still not
Pattern a girlfriend & getting his priority in life
married. But he has
crush at their school
Coping Stress • He doesn’t fully • Same • He doesn’t mind the
 & Tolerance identify his stressors. stressors in life.
Pattern
Activity- • His daily routine on • He interacts with his • He only focuses on
Exercise playing computer. grandmother & other simple things.
Pattern His daily activities people around him
were limited in
• Cooperates well to
waking up in the
the doctor & nurses.
morning to attend his
class & after that
going to computer
shop.
Value-Belief • He is a Catholic and • Still the same • Due to their culture
Pattern they have lots of preferences &
beliefs in their house parent’s influence
like they should offer
fruits and foods to
their dead relatives
Health •He perceived that he • He thinks that he • He changed his
Perception – will always be in the needs to take good perception about
Pattern state of good care of his health and health, when he
condition do not disregard it realizes how
important it was.

Patterns of Functioning

The patient mostly eats bread and drinks more water unlike before the
hospitalization that he drinks more soft drinks and juice. However, recently he does not have an
appetite to eat or drinks and he said that he feels weak.
Daily Activity Patterns

Most of the time the patient was sleeping and sometimes it was interrupted because his
vital signs were taken every hour and the doctor advised his mother to wake him up every time
it was taken.

In the hospital, he wakes up at around 7 am to eat his breakfast, then he will go back to
sleep and as what have said in the paragraph above his sleep was interrupted every hour, but he
was able to sleep again after his vital signs was taken. At 12:00 noon he will eat his lunch and
sometimes talks to his mother or sister. Around 10:00 pm he will sleep after taking his
medicines.

Patient’s Concept of Health and Hospitalization

The patient perceived that he will always be in the state of good condition and that
health will determine if the person is weak or strong. He also added that before he just think
that his fever will just go away for a day.

Now, he thinks that he needs to take good care of his health and do not disregard it,
because as he experienced now, it is hard to have a disease like the one that he has since he
cannot do everything that he wants and can’t go out with his friends and even attend the school.
His perception about health was changed, when he was hospitalized and he also realizes how
important it was.

Laboratory and Diagnostic Examination

Rh Typing

Anti A Anti B Rh Anti O Reverse typing

- - +4 +3

ABO and Rh: O+

The patient’s blood type is O+. This test is useful and very important for blood
transfusion.

Hematology Report 11/24/10

Test Result Normal Value

WBC 5.1 4.5-13.5
Neutrophils 37 0.24-0.74
Lymphocytes 37.8 0.29-0.49
Monocytes 0.6 0.020-0.09
Eosinophils 0.7 0-3
RBC 4.47 4.0-6.20
HgB 13.7 14-18
HCT 0.37 37-47
MCV 82.8 81-99
MCH 29.7 27-31
MCHC 0.36 32-36
RDW 127 0.115-0.140
Platelet 93 150-400
 In the hematology report, it can be seen that the platelet of the patient was increased, but
it still does not reached the normal range.

Hematology Report 11/23/10

Test Result Normal Value

WBC 3.3 4.5-13.5
Neutrophils 4.2 0.24-0.74
Lymphocytes 56 0.29-0.49
Monocytes 2 0.020-0.09
RBC 4.85 4.0-6.20
HgB 14.1 14-18
HCT 40.1 37-47
MCV 82.8 81-99
MCH 29.2 27-31
MCHC 35.2 32-36
RDW 128 0.115-0.140
Platelet 10 150-400

PT and PTT 11/22/10

Test Result Unit

PT
Normal value 11.0 sec
Pt. Value 12.1 sec
% Activity 0.73 %
- inr 1.23 inr
Activated PTT
Normal value 34.7 sec
Pt. Value 88.8 sec

Hematology Report 11/22/10

 Test Result Normal Value
WBC 1.7 4.0-10.0
Neutrophils 4.6 0.24-0.74
Lymphocytes 43.6 20.0-40.8
Monocytes 10.3 3.0-9.0
Eosinophils 20 2.0-4.0
RBC 5.57 3.0-6.0
HgB 153 140-180
HCT 0.42 0.40-0.54
MCV 74.3 81-99
MCH 27.4 27-31
MCHC 36.7 32-36
RDW 125 0.115-0.140
Platelet 36 150-400

Hematology Report 11/18/10

Test Result Normal Value

WBC 6 4.8-10.8
Neutrophils 67 55- 75
Lymphocytes 20.4 20-30
Monocytes 7.6 0-7
RBC 4.86 4.0-6.20
HgB 13.8 14-18
HCT 38 37-47
MCV 85 81-99
MCH 28.6 27-31
MCHC 34.5 32-36
RDW 6.8 0.115-0.140
Platelet 141 150-400
Impression Diagnosis

On the blood typing, the patient’s blood type is O+. This test is useful and very
important for blood transfusion since the patient will be transfused of fresh frozen plasma 2
units.

The hematology report is done to determine the exact value of each blood component. It
is also one of the most commonly used for diagnostic tests and can provide valuable
information about the hematologic system and many other body systems since blood circulates
throughout the body.

An increase in leukocytes and segmented leukocytes indicates an infection. RDW were

high, indicates possibly thrombocytosis, hemorrhage, infections and or malignancy. An
increase in lymphocytes indicates a chronic bacterial infection or there may be a viral infection.

The PT and PTT were important also, since they were clotting factors, which is an
important test to know the status hematology system of the patient and to identify if transfusion
will be needed.
Course in the Ward

The patient was admitted under the service of Dr. Manaligid/ Dela Cruz/ Robles.
Consent was secured from the patient. The diagnostic test done was CBC with PC.

1. Oresol 1 sachet for volume/volume replacement

2. Probiotic 1 cap + 30 cc H2O

3. Prozinc syrup 10 ml OD x 2 weeks

4. Paracetamol tab prn q4 for Temp > 37.8 oC

The patient was inserted an intravenous fluid of Plain Lactated Ringer (PLR) on his
right arm which was regulated at 52-53 ugtts/min. He was on diet as tolerated (DAT) except
dark colored foods.

On November 22, 2010, the doctor ordered for PT, PTT and CBC with PC. TSB was
rendered whenever fever occurs and paracetamol was given everytime the fever of the patient
reached to 37.8 oC.

On November 23, 2010, the results of PT, PTT and CBC with PC was secured. The
patient was for repeat CBC with PC and if was found out in the result that his platelet count
was only 10, consequently, 2 units of Fresh Frozen Plasma (FFP) was ordered to be transfused
to the patient and for cross matching.

On November 24, 2010, the patient was for repeat CBC with PC. The patient’s
intravenous fluid, Plain Lactated Ringer (PLR), on his right arm was changed from micro set to
macro set, in turn, the regulation was also changed from 52-53 ugtts/min to 31-32 gtts/min.
III. CLINICAL DISCUSSION OF THE DISEASE

Anatomy and Physiology

The Immune System

A second line of defense is housed within the body: a finely tuned immune system that
recognizes and destroys foreign substances and organisms that enter the body. The immune
system can distinguish between the body's own tissues and outside substances called antigens.
This allows cells of the immune army to identify and destroy only those enemy antigens. The
ability to identify an antigen also permits the immune system to remember antigens the body
has been exposed to in the past; so that the body can mount a better and faster immune response
the next time any of these antigens appear.

The immune system also includes other proteins and chemicals that assist antibodies
and T cells in their work. Among them are chemicals that alert phagocytes to the site of the
infection. The complement system, a group of proteins that normally float freely in the blood,
move toward infections, where they combine to help destroy microorganisms and foreign
particles. They do this by changing the surface of bacteria or other microorganisms, causing
them to die.

Components of the Immune System:

1. Lymphoid Structures

· Spleen

- Composed of red and white pulp, acts somewhat like a filter.

- The red pulp is the site where old and injured red blood cells are destroyed.

- The white pulp contains concentrations of lymphocytes.

· Lymph Nodes

- Are distributed throughout the body

- Are connected by lymph channels and capillaries, which remove foreign material from the
lymph before it enters the bloodstream.

2. Immune Cells – Lymphocytes

a. B lymphocytes (or B cells) - produce immunoglobulins.

b. T lymphocytes (or T cells) - help control the immune response and destroy foreign
antigens directly.

c. Plasma Cells - are white blood cells that produce large volumes of antibodies.

3. Tissues – The remaining lymphoid tissues, such as the tonsils and adenoids and other.

Mucoid Lymphatic Tissue – contain immune cells that defend the body’s mucosal surfaces
against microorganisms.

4. Immune Cells – Lymphocytes

 • B lymphocytes (or B cells) - produce immunoglobulins.
• T lymphocytes (or T cells) - help control the immune response and destroy foreign
antigens directly.
• Plasma Cells - are white blood cells that produce large volumes of antibodies.

2 Types of Immunity

• Active – acquired through previous exposure of the disease or through immunization

wherein the body “actively” participates in formation of antibodies for future reference.
• Passive – refers to whole, “ready made” immunity acquired from another, the body is
just “passive” in the process of developing antibodies, as it is already made and given
readily.

4 Types of Active Immunity

a. Humoral Immunity
b. Mucosal Immunity
c. Cell-mediated Immunity
d. Delayed Hypersensitivity Reaction

Hematologic System

Two types of blood vessels carry blood throughout our bodies:

1. Arteries carry oxygenated blood (blood that has received oxygen from the lungs) from the
heart to the rest of the body.

2. Blood then travels through veins back to the heart and lungs, where it receives more oxygen.

The blood that flows through this network of veins and arteries is whole blood, which
contains three types of blood cells:

1. Red blood cells (RBCs)

 • (Also called erythrocytes) are shaped like slightly indented, flattened disks. RBCs
contain the iron-rich protein hemoglobin. Blood gets its bright red color when
hemoglobin picks up oxygen in the lungs. As the blood travels through the body, the
hemoglobin releases oxygen to the tissues.

2. White blood cells (WBCs)

• (Also called leukocytes) are a key part of the body's system for defending itself against
infection. They can move in and out of the bloodstream to reach affected tissues. Blood
contains far fewer WBCs than red blood cells, although the body can increase WBC
production to fight infection. There are several types of WBCs, and their life spans vary
from a few days to months. New cells are constantly being formed in the bone marrow.

3. Platelets

• (Also called thrombocytes) are tiny oval-shaped cells made in the bone marrow. They
help in the clotting process. When a blood vessel breaks, platelets gather in the area and
help seal off the leak. Platelets survive only about 9 days in the bloodstream and are
constantly being replaced by new cells.
 • Platelets and clotting factors work together to form solid lumps to seal leaks, wounds,
cuts, and scratches and to prevent bleeding inside and on the surfaces of our bodies. The
process of clotting is like a puzzle with interlocking parts.

Definition and Description of the Disease

Dengue fever is a type of arbovirus, which is short for arthropod-borne virus. The virus
that causes dengue fever is carried by Aedes egypti mosquitoes, and is transmitted to humans
through their bite. An organism that carries a disease, without actually developing the disease,
is called a vector. Dengue fever is most prevalent in Southeast Asia, but also occurs in Africa,
Europe, South America, and southern regions of North America (South Texas). It may also
occur in non-endemic regions in travellers from endemic regions.

The disease can occur in two forms: (1) Dengue Fever (DF) and (2) Dengue
Haemorrhagic Fever/Dengue Shock Syndrome (DHF/DSS). DF is marked by the onset of
sudden high fever, severe headache and pain behind the eyes, in the muscles and in the joints
and without increased vascular permeability. DHF is a more severe form, in which increased
vascular permeability and fragility, evidence of pleural effusion, ascites or hemoconcentration
> 20%, bleeding and sometimes shock occurs, leading to death. It is most serious in children.
Dengue spreads rapidly and may affect large numbers of people during an epidemic resulting in
reduced work productivity, but most importantly causing the loss of lives.

Drug Study

Paracetamol

Generic Name: Paracetamol

Brand Name: Biogesic

Classification: Antipyretic, Analgesic (nonopioid)

Mode of Action:

Reduces fever by acting directly on the hypothalamic heat regulating center to cause
vasodilation and sweating, which helps dissipate heat.

Indication:

For fever reduction and Analgesic-anipyretic in patients with aspirin allergy.

Contraindication:

Contraindicated with allergy to acetaminophen.Use cautiously with impaired hepatic

function, chronic alcoholism, pregnancy, lactation

Ordered Dose: 1 tab 500 mg prn q4 for Temp > 37.8 oC

Drug Interaction:

Increased toxicity with long-term, excessive ethanol ingestion. Increased

hypoprothrombinemic effect of oral anticoagulants. Increased risk of hepatotoxicity and
possible decreased therapeutic effects with barbiturates, carbamazepine, hydantoins, rifampin,
sulfinpyrazone. Possible delayed or decreased effectiveness with anticholinergics.

Side Effects:

Headache, Chest pain, dyspnea,

Adverse Effects:

Rash, cyanosis; hemolytic anemia (hematuria, anuria); neutropenia, leukopenia,

pancytopenia, thrombocytopenia, hypoglycemia Acute kidney failure, renal tubular necrosis

Nursing Responsibilities:

• Do not exceed the recommended dosage.

• Give drug with food if GI upset occurs.

• Check I&O ratio; decreasing output may indicate renal failure.

 • Assess for fever and pain

• Assess hepatotoxicity: dark urine, clay-colored stools

• Discontinue drug if hypersensitivity reactions occur.

• Treatment of overdose: Monitor serum levels regularly, N-acetylcysteine should be

available as a specific antidote; basic life support measures may be necessary.

• Do not exceed recommended dose

• Take the drug only for complaints indicated.

• Advised the patient and significant others to report rash, unusual bleeding or bruising,
yellowing of skin or eyes, changes in voiding patterns.

Ranitidine

Generic name: Ranitidine

Brand name: Zantac

Classification: Anti ulcer drug

Mode of Action:

Inhibits the action of histamine at the H2 receptor site located primarily in gastric
parietal cells, resulting in inhibition of gastric acid secretion.

Indication:

Prevention and treatment of self stress induce upper GI bleeding in critically ill patient.
Short term treatment of active duodenal ulcers and benign ulcer. Prevention and treatment of
heartburn, acid ingestion and sour stomach

Contraindication:

Porphyria, Hypersensitivity, Renal impairment, some products contains aspartame and

should be avoided in patients with phenylketonuria

Side effect:
 Headache (may be severe); drowsiness, dizziness; sleep problems (insomnia); decreased
sex drive, impotence, or difficulty having an orgasm; or swollen or tender breasts (in men);
nausea, vomiting, stomach pain; or Diarrhea or constipation. drowsiness, dizziness; decreased
sex drive, impotence, or difficulty having an orgasm; or swollen or tender breasts (in men);
nausea, vomiting, stomach pain; or Diarrhea or constipation

Adverse effect: arrhythmias, agranulocytosis, aplastic anemia.

Dosage: 42 mg q8o TIV

Nursing Responsibility:

• Assess for epigastric pain or abdominal pain and frank or occult blood in the stool,
emesis or gastric aspirate.
• Instruct patient to take without regard to meals because absorption isn’t affected by
food
• May cause increase in serum transaminase and serum creatinine
• Ranitidine may cause false positive results for urine protein, test with sulfosalicylic
acid.
• Inform the patient that increase fluid and fiber intake and exercise may minimize
constipation.
• Instruct the patient to take the medication as directed for the full course of therapy, even
if feeling better.

NURSING CARE PLAN

\

Discharge Plan

Medication
1) Instruct the patient about the importance of taking the medication regularly and in complying
with the treatment regimen

Complying with the treatment regimen as prescribed will help prevent further
complication

2) Discuss with the significant others and to the client regarding the names of drugs, its dosage,
time of administration, its possible side effects and right way of taking it.

Awareness of the medication would encourage patient to comply means for faster recovery

3) Instruct patient and significant other to verify the medicine label and compare it to the
prescription sheet before taking it.

To ensure safety in taking the drugs.

4) Do not administer any drugs that are not prescribed by the physician. Do not intent to self
medicate.

Drugs taken with other drugs may have an antagonist or synergistic effect which may
aggravate patient’s present condition

5) It is important that the patient should follow and complete the whole course of the drug
therapy.

To alleviate the status of the patient leading to faster recovery.

6) Tell the patient and the significant other to report any untoward sings and symptoms for the
side effects of the drugs being taken

To reduce further complications and prompt interventions may be given.

Exercise
1) Encourage patient to have a good exercise such as passive ROM according to his capacity

To improve physical fitness, improve emotional state and weight control as it promote a
good circulation

2) Encourage to have a deep breathing exercise.

To promote relaxation and prevent pulmonary congestion.

Treatment

1) Explain to the family about the present condition and the factual information about the said
disease.

To give a better information and education about the patient’s underlying condition

2) Tell patient to take the medications regularly.

To provide a faster recovery

Hygiene:

1) Encourage patient to take a bath everyday.

Knowing its importance and proper interventions adds encouragement and prevents
infection.

2) Instruct that it is essential to have a good and clean environment.

To prevent infections and possible disease and promoting comfort.

Outpatient referrals

1) Encourage patient and significant for follow-up check-ups regularly.

To monitor the underlying condition of the patient.

2) Instruct the client to make an appointment with their physician for 7 to 10 days after the
discharge.
 To monitor progress and to monitor recurrence of disease.

Diet

1) Advice patient to increase oral fluid intake.

This is important for circulation and elimination.

2) Encourage patient to eat nutritious foods according to her plan to maintain her normal body
weight and to stay healthy.

To achieve and maintain nutritional status.