Vicente Sotto Memorial Medical Center B.

Rodriguez Street, Cebu City

Nursing Service Division Training Office

A CASE REPORT ON DENGUE HEMMORHAGIC FEVER

Submitted by: Omega, Kristian Suansing, Joanne Nuez, Nia Fe R. Toremotcha, Reanne

Emergency Room

Nov. 14, 2011 February 29, 2012 I. INTRODUCTION

Dengue fever is an infectious disease carried by mosquitoes and caused by any of four related dengue viruses. This disease used to be called breakbone 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. 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.

II. STATEMENT OF THE OBJECTIVES

General Objectives This case study aims to identify and determine the general health problems and needs of the patient with an admitting diagnosis of Dengue Hemorrhagic Fever. This presentation also intends to help patient promote health and medical understanding of such condition through the application of the nursing skills. Specific Objectives This study is aimed to promote health of the chosen patient qualitatively by learning about the patients condition. To raise the level of awareness of patient on health problems that he may encounter. To facilitate patient in taking necessary actions to solve and prevent the identified problems on his own. To help patient in motivating his 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. To know the causes of Dengue Hemorrhagic Fever. To identify the different clinical manifestation of the condition. To determine the possible medical and surgical management of this condition. To provide nursing care and information to patient through the application of the nursing skills.

III.PATIENTS PROFILE

NAME AGE GENDER ADDRESS DATE OF BIRTH PLACE OF BIRTH OCCUPATION NATIONALITY CIVIL STATUS RELIGION CHIEF COMPLAINT FINAL DIAGNOSIS

: : : : : :

R. F. N. 19 years old Male Tulay, Minglanilla Cebu January 08, 1993 Cebu City : : : N/A Still a student Filipino Single

: : :

Roman Catholic Fever Dengue Fever Dr. Bernice Ann Espina January 10, 2012 12:18 PM : Vicente Sotto Memorial

ATTENDING PHYSICIAN : DATE ADMITTED TIME ADMITTED : :

ADMITTING INSTITUTION Medical Center

History of Present Illness: Three days prior to admission the patient has fever and loss of appetite. According to the SO of the patient, they went to consult a physician during the first day of his fever. The physician prescribed Paracetamol for the patient. On the third day, the patient still had the said symptoms. He went back for a check-up. He had CBC and was determined that he has dengue. The patient then was admitted immediately. History of Past Illness: According to the SO of the patient the patient did not yet experienced having serious health problems other than fever, colds and cough. Family History: Patient has no known allergies in food and drugs, no history of cigarette and tobacco use. He doesnt have any hereditary diseases such as hypertension, diabetes mellitus and asthma.

Gordons Functional Health Pattern I. Health Perception-Health Management Pattern Previous admission was due to fever and epigastric discomfort. He has no history of alcohol intake and smoking. He usually eats vegetables and fish, drinks water enough for her to have a normal bowel movement, usually every morning after breakfast. His activities of daily living is cooking, cleaning the house and washing clothes. II. Nutritional Metabolic Pattern

When the patient was admitted he lost his appetite to eat. Skin was noted to be smooth and warm to touch, hair is black in color, nails both in hands and feet are clean and mucous membrane is quite dry. III.Elimination Pattern The patients normal bathroom habit is every morning after eating breakfast. He drinks more fluids and eats papaya and vegetables if hell not defecate for two days and more. He estimates urinating five to nine times a day including night time. IV.Activity-Exercise Pattern Being confined in the hospital affects the patients functional abilities such as loss of appetite and grooming. Before he was admitted he considers walking going to school as his physical exercise. During weekends, he spends his time with his family and spares some time for his friends. He is accommodating and amiable to the health care provider and is cooperative especially when it comes to complying with his meds. V. Sleep-Rest Pattern Patient doesnt have any sleep pattern disturbance, he dont take any medications to induce sleep. He usually falls asleep around 10 in the evening and wakes up at 5 in the morning. Sometimes he is awakened by the noise in the ward and every time nurses comes in to check on him, to get vital signs and give medications. VI.Cognitive Perceptual Pattern He is normal in terms of his cognitive abilities. He has good memory and reasoning skills. He can easily comprehend on things. In terms of his perceptual pattern, he has no problems with his senses. He responds clearly and well understood. He has no sensory deficit; he responds appropriately to verbal stimuli and obeys simple commands. VII. Self-Perception-Self Concept Pattern He sees himself as a person with good personality. He has been a good friend, brother and a son. He said he has to be a good person in order not to hurt others. He also describes himself as a typical type of student and person.

VIII. Role-Relationship Pattern He has a close family relationship with his family. They were five siblings in their family. He was at the middle. I was also able to ask his mother about his being a son and he confessed that he is a good son but at times he doesnt obey her. He is also a responsible student and knows all his duties as a friend. IX.Sexuality-Reproductive Pattern According to him, he doesnt think of the things like having a girlfriend and getting married yet. He is still young for such matters.

X. Coping-Stress Tolerance Pattern He does not fully identify his situations having stress but he always tell his parents when something is wrong. He share his problem to his family, he verbalizes his feelings. XI.Values-Belief Pattern He is a Roman Catholic devotee. He seldom goes to church but he was taught by his family to believe and have fear to God. They usually believe in quack doctors.

IV.

PATHOPHYSIOLOGY

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 Erythrocytes (RBC) Description Biconcave disk, no nucleus, 7-8 micrometers in diameter. Spherical cell, nucleus with two or more lobes connected by thin filaments, cytoplasmic granules stain a light pink or reddish purple, 12-15micrometers in diameter Spherical cell, nucleus, with two indistinct lobes, cytoplasmic granules stain blue-purple, 1012micrometers in diameter Spherical cell, nucleus often bilobed, cytoplasmic granules satin orange-red or bright red, 10-12 micrometers in diameter Spherical cell with round nucleus, cytoplasm Function Transports oxygen and Carbon dioxide.

Leukocytes (WBC) Neutrophil Phagocytizes microorganism

Basophil

Eosinophil

Releases histamine, which promotes inflammation, and heparin which prevents clot formation Releases chemical that reduce inflammation, attacks certain worm parasites Produces antibodies and other chemicals

Lymphocyte

Monocyte

forms a thin ring around the nucleus, 6-8 micrometers in diameter

Spherical or irregular cell, nucleus round or kidney or horse-shoe shaped, contain more cytoplasm than lymphocyte, 10-15 micrometers in diameter

Platelet

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

responsible for destroying microorganisms, responsible for allergic reactions, graft rejections, tumor control, and regulation of immune system Phagocytic cell in the blood leaves the circulatory system and becomes a macrophage which phagocytises bacteria, dead cells, cell fragments, and debris within tissues Forms platelet plugs, release chemicals necessary for

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 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 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 throughtout 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 forming.

Physiology
Dengue hemorrhagic fever is caused by a wide strain of Flaviviruses which is carried by the female Aedes aegypti mosquito. Risk factors include: living in Tropical Areas ( Africa, Southeast Asia and China, India, Middle East, Caribbean and Central and South America, Australia and the South and Central Pacific) where incidence and prevalence are high; age, in which children are more prone to acquiring the disease; immune status, in which immunocompromised clients acquire the disease faster; type of infecting virus, as some strains of the Flavivirus are more virulent than others; and lastly, those who have been previously infected. The virus is not contagious and cannot be spread directly from person to person. There must be a person-tomosquito-to-another-person pathway. After being bitten by a mosquito carrying the virus, the incubation period ranges from three to 15 (usually five to eight) days before the signs and symptoms of dengue appear. Dengue starts with chills, headache, pain upon moving the eyes, and low backache. Painful aching in the legs and joints occurs during the first hours of illness. The temperature rises quickly as high as 104 F (40 C), with relative low heart rate (bradycardia) and low blood pressure (hypotension). The eyes become reddened. A flushing or pale pink rash comes over the face and then disappears. The glands (lymph nodes) in the neck and groin are often swollen. (Black and Hawks, 2004) Fever and other signs of dengue last for two to four days, followed by rapid drop in temperature (defervescence) with profuse sweating. This precedes a period with normal temperature and a sense of well-being that lasts about a day. A second rapid rise in temperature follows. A characteristic rash appears along with the fever and spreads from the extremities to cover the entire body except the face. The palms and soles may be bright red and swollen. Within a few days, viremia occurs, lasting until the 4th or 5th day after the onset of symptoms. At the site of petechial rashes, non-specific changes can be noted. There is marked increase in vascular permeability, hypotension, hemoconcentration, and thrombocytopenia. An alarmic physiologic change is the hypovolemic shock which is caused by the leak of interstitial fluid due to increased permeability of the vessels and massive bleeding due to hemoconcentration partnered with thrombocytopenia. The patient lives in a tropical area the Philippines wherein Dengue Fever has been rampant. Patients living condition as verbalized by him is crowded; furthermore, patient claimed that theyre water system is the

artesian well, wherein they store water on large drums. Patient reported that cases of Dengue have increased in the vicinity of his resident. As what have stated in the pathophysiology on dengue hemorrhagic fever, the patient is predisposed of having the disease since he has several risk factors. Patients signs and symptoms were: chills, headache, pain upon moving the eyes, low backache, Fever, muscle pain, rashes, flushing, orthopnea and vomiting, slight dehydration.

Risk factors: Young adults Immune system compromised

Agent: Flavivirus

Environment: Damage drainage system Open canals Uncovered pails Open stagnant water

Schematic diagram of the Pathophysiology of Dengue Hemorrhagic Fever Virus enters the bloodstream
Increase in vascular permeability

Introduction of the causative agent by the bite of the carrier to a susceptible host

Hypotension

Hemoconcentration

Thrombocytopenia

Leak of interstitial fluid

Massive bleeding

Hypovolemic shock Signs and symptoms: Chills Headache Pain upon moving the eyes Low backache ; slight dehydration Painful aching in the legs and joints Temperature rises quickly as high as 104 F (40 C) Relative low heart rate (bradycardia) Low blood pressure (hypotension)

V. COURSE IN THE WARD DENGUE HEMORRHAGIC FEVER Table 1. Urinalysis Color Reaction Sugar Squamous epithelial RBC Yellow 6 Negative Few 0 1/hpf Transparency Specific gravity Protein Bacteria Pus cells Slightly cloudy 1.00 Negative Few 0 -1/hpf

Urinalysis is a laboratory procedure, done by collecting a urine sample via midstream, clean-catch method, used to determine the macroscopic and microscopic characteristics and qualities of the urine in order to gather supporting evidence for a medical diagnosis. The table above shows no deviations to be noted.

Table 2. Complete Blood Count Test Result Result Result 9-219-22-09 9-23-09 09 WBC Hgb Hct MCV MCH RBC MCHC RDW MPV Platelet count Neutrophil Lymphocyt e Monocyte Eosinophil 14 122 0.57 85 28 4.3 332 13 7.5 101 55 42 3 2 13.5 125 0.54 86 28 4.4 335 13.2 7.4 120 53 40 4 1 12.4 125 0.50 84 28 4.5 342 13.4 7.4 135 56 41 3 1

Result Referen 9-24ce 09 4.8 10.7 10.8 120 128 160 0.37 0.47 0.47 84 81 99 28 27 31 4.5 330 12.7 7.9 151 550 40 3 0 4.2 5.4 330 370 11.0 16.0 7.2 11.1 150 400 40 74 19 47 39 07

Unit

10^9/L g/L L/L Fl Pg 10^12/ L g/L % Fl 10^9/L % % % %

Complete Blood Count is a set value of the cellular (formed elements) of blood. These measurements are generally determined by specially designed machines that analyze the different components of blood in less than a minute Table 2 shows the different complete blood count results from September 21 to September 24, 2009. As revealed in the table, there is a markedly increased in the WBC and a decreased in the platelet count in the first three results. This noticeable changes could predispose bleeding and infection. The Hematocrit was above the normal range for the three consecutive results that could mean dehydration. The low levels of WBC indicate the clients predisposition to infections. The combined thrombocytopenia and high hematocrit count poses a great risk for massive bleeding. There is delayed clotting and due to hemoconcentration, there is altered tissue perfusion. The result for the last test displayed return to normal levels of all blood components. The evident progression in the results could imply an improvement of the patients condition.

Pharmacologic Therapy
Paracetamol The patient was given paracetamol 500mg 1 tablet P.O to be given as necessary if the Temperature is >38.5C. The drug is a non opioid analgesic and an antipyretic which is generally indicated to reduce fever and for control of pain due to headache, and musculoskeletal pain. Patient has been given the drug whenever body temperature reaches 38.5C and above. When given, patients temperature would soon drop back to normal levels. In the six days of care, a pattern of rise in temperature and the giving of paracetamol causing its decline were common. Nursing responsibilities would include assessing the temperature before, during and after the administration. Instruct patient to avoid drinking alcohol as it increases liver toxicity. Instruct to take drug as it is. Document after drug is given to the patient. Instruct to report any unusualities. Vitamin B-Complex. The patient was given Vitamin B complex with a dosage of one tablet once a day. This drug is a coenzyme that stimulates metabolic function and is needed for cell replication, hematopoeisis, and nucleoprotein and myelin synthesis. Patient has given drug once a day without missing a dose to ensure optimum prevention of toxicity. Patient did not show any signs of drug over dosage. The patient was instructed to take the drug as prescribed and not to take large doses to prevent overdosage of the drug that may cause any discomfort. Nursing responsibility is to verify doctors order, check if patient has hypersensitivity to drug, obtain baseline vital signs, review drug regimen for possible drug interaction, give drug as it is, monitor patient for any adverse effects. Intravenous Therapy The goal of intravenous fluid (IV) administration is to carefully achieve and maintain a euvolemic and isotonic environment within the body as well as to provide for a variety of nutritional and pharmacologic interventions. Compared with other routes of administration, the IV route is the fastest way to deliver fluids and medications into the body. Some medications, as well as blood transfusions can only be given via this route. The selection of an appropriate IV solution is dependent upon the fluid volume and electrolyte status of the individual patient as well as any additional specific therapeutic goal.

Upon admission, September 21, 2009, patient was given with an IV solution of Lactated Ringers Solution at the rate of 30 drops per minute. The IV solution was given to the patient for water and electrolytes replacement. This fluid was used to increase the fluid volume of the patient to address and prevent further dehydration. This intravenous (IV) solution used to supply water and electrolytes (e.g., calcium, potassium, sodium, chloride), either with or without calories (dextrose), to the body. It is also used as a mixing solution (diluent) for other IV. This solution was continued until the day the patient was discharged. Its main nursing responsibility is to watch out for hypervolemia due to the fluids volume expander property.

VI.

THEORITICAL FRAMEWORK

Mr R.F.N., was diagnosed of having Dengue Hemorrhagic Fever. At the Vicente Sotto Memorial Medical Center, the physician was able to identify some clinical signs of it. The case of Miss X can be correlated with the theory of Florence Nightingale. Application Theory: The case of Mr R.F.N. 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.

VII. NURSING CARE PLAN

In this chapter, different nursing care plans based on the patients need will be discussed to fully understand the patients problems and to render efficient and effective care. Ineffective Thermoregulation related to increased metabolic rate secondary to disease process. The short term goal of this problem was for the patient to be able to achieve a normal body temperature as evidenced by an axillary temperature of 36.5 degrees Celcius to 37.5 degrees Celcius. The long term goal of this problem was for the patient to be able to maintain vital signs within normal range and be free of complications. In rendering nursing care, continuous assessment of patients temperature every hour is done to monitor rise in temperature. Patient is advice to avoid wearing constrictive clothing to promote proper ventilation. Patient is also

advice to increase oral fluid intake to prevent dehydration caused by hyperthermia. The nurse performs tepid sponge bath to promote heat loss as necessary. The nurses also maintain bed rest to reduce unnecessary oxygen demands. Give medications as indicated. Evaluation parameters include the axillary temperature (must be within 36.5 degrees Celsius to 37.5 degrees Celsius), a decrease in the warmth of the skin of the patient, and diaphoresis. Decreased Cardiac Output related to decreased Cardiac Contractility. The short-term goal for this problem was for the patient who will be able to maintain BP within normal limits; warm, dry skin; regular cardiac rhythm; clear lung sounds; and strong bilateral, equal peripheral pulses. The long-term goal for this problem was for the patient to be free of any signs of impending complications. In rendering nursing care for this condition, the nurse must constantly monitor and chart vital signs to monitor radical changes in the patients condition. The nurse also positions with head of bed flat or keep trunk horizontally while raising legs 20 to 30 degrees to maximize cardiac output. The nurse should promote adequate rest to decrease workload of the heart. The nurse also charts the patients intake and output accurately to maintain correct fluid and electrolyte balance. Giving of medications as indicated is also observed. The nurse also assists with or performs self-care activities for the patient to reduce cardiac workload brought about by exertion. The evaluation parameter set for this problem is that the heart rate of the patient is within normal ranges, which is 80 beats per minute. Disturbed Sleeping Pattern related to humidity and excessive noise stimulation from the environment. The goal for this problem is for the patient to achieve optimal amounts of sleep as evidenced by rested appearance, verbalization of feeling rested, and improvement in sleep pattern. In giving nursing care to this patient, the nurse should let patient understand that the nature of the environment is prone to noise. The nurse should also cluster care to the patient to save patients time and energy and give him more time to sleep. The nurse is to advise patient to drink warm milk to promote sleep, as warm milk contains tryptophan, an amino acid responsible for inducing sleep. The nurse also provides some environmental comfort measures, such as bed making to further promote sleep. Also, the nurse must advise patient to avoid day naps to make the patient as sleepy as possible during the night. The evaluation parameter for this problem is the return of the patients amount and quality of sleep to the pre-hospitalization state.

Risk for deficient fluid volume: isotonic related to hemorrhage secondary to possible mesenteric infection. The overall goal for this problem is for the patient who will be able to experience an adequate fluid volume and electrolyte balance as evidenced by urine output greater than 30 ml/hr, normotensive blood pressure (BP), heart rate (HR) 100 beats/min, consistency of weight, and normal skin turgor. In rendering care to this patient, the nurse must encourage patient to drink prescribed fluid amounts. Assist patient if unable to feed self and encourage caregiver to assist with feedings as appropriate. Provide oral hygiene. This promotes interest in drinking. Institute measures to control excessive electrolyte loss (e.g., resting the GI tract, administering antipyretics as ordered). Teach interventions to prevent future episodes of inadequate intake. Patients need to understand the importance of drinking extra fluid during bouts of diarrhea, fever, and other conditions causing fluid deficits. The evaluation parameter set for the problem is that the patient was able to attain an adequate in fluid volume and electrolyte balance as evidenced by a urine output of 720 ml in 8 hours. Risk for Injury related to decreased energy levels of the patient. The short term goal for this problem was for the patients condition that will be stabilizing within 72 hours. The long term goal for this problem was for the patient will be able to be free from risk in injury. In rendering care to this patient, the nurse must place client in quiet, private room. Excessive stimuli increase client agitation. The nurse must also institute necessary safety precautions such as a.)Observing client behaviors frequently; assign staff on one-to-one basis if condition is warranted; accompany and assist client when ambulating; use wheelchair for transporting long distances, b.)Be sure that side rails are up when client is in bed, c.)Pad headboard and side rails of bed with thick towels to protect client in case of seizure, d.)Use mechanical restraints as necessary to protect client if excessive hyperactivity accompanies the disorientation. The nurse should also frequently orient client to reality and surroundings. Disorientation may endanger client safety if he or she unknowingly wanders away from safe environment. Lastly, the client must follow medication regimen, as ordered by physician. The evaluation parameter set for the problem is that the patient was able to have an environment which is free from injurious elements and was able to rest comfortably.

VIII. Discharge Plan

The discharge plan for the patient is set to be on October 10, 2009. Patient would be going back home to Tulay, Minglanilla Cebu via wheelchair using a public utility jeepney (PUJ). Patient would be continually seeking assistance and have his follow up check-ups from Vicente Sotto Memorial Medical Center. Teachings include follow-up health teachings regarding the take-home medications. He was also instructed to eat adequate amounts of nutritious foods as well as complying with the continued medication regimen. Emphasis should be placed on the correct timing and dosage of the drug, as well as strict adherence to the medication regimen ordered by the physician. Additional information about the Department of Healths 4 OClock Habit must be given as well, in order to prevent another incidence of dengue attacks. Encouragement about a positive shift in the lifestyle of the patient must be given, since medications will be useless if the patient himself would not take measures to safeguard his health. The patients family members were encouraged to take care of him and reinforcing the appropriate care to be rendered to their patient. The family was conferred on the patients lifestyle modifications such as facilitating adequate rest and exercise as well as cessation of smoking or exposure to environmental air pollution and home management for the disease.

IX.

Conclusion

After having cared for the patient within the study period, the author learned that Dengue fever and dengue hemorrhagic fever (DHF) are caused by four closely related virus serotypes of the genus Flavivirus, family Flaviviridae. It is also known as breakbone fever. Dengue is transmitted to humans by the Aedes aegypti or more rarely the Aedes albopictus mosquito, which feed during the day. The author also learned that rheumatic heart disease involves damage to the entire heart and its membranes. Rheumatic heart disease is a complication of rheumatic fever and usually occurs after attacks of rheumatic fever. In DHF, there is bleeding with easy bruising, blood spots in the skin (petechiae), spitting up blood (hematemesis), blood in the stool (melena), bleeding gums, and nosebleeds (epistaxis). Patients with DHF must be monitored closely for the first few days since shock may occur or recur precipitously. Patients with rheumatic heart disease usually show signs of breathlessness, fatigue, palpitations, chest pain, and fainting attacks. The best way to prevent rheumatic heart disease is to seek immediate medical attention to a strep throat and not let it progress to rheumatic fever. However, studying more about the case presented broadened the nurses perspective in managing clients with such a disease. Patients with DHF and RHD are indeed curable unless left untreated. The primary goals of treatment are to relieve symptoms and prevent complications. It can be

managed independently by the client with the aid of his significant others. Pharmacologic and non-pharmacologic interventions must be strictly implemented to increase the chance of early recovery and prevent untoward complications.

X. RECOMENDATIONS For the purpose of improvement, the researcher would like to recommend the following: To the healthcare team The healthcare team should continue in rendering care for these kinds of clients. They should initiate and be firm on the infection spread control within the ward. Focus should be on other alternative management of the disease or if not other means of enhancing the patients condition be done. More knowledge regarding the care for these clients gives them better chances of recovering from a dreadful disease. Further self-research and learning about communicable diseases would deem helpful both for the health care professional and the clients. To the healthcare agency or institution Promoting the maintenance of health and well being of people in the society should be done through seminars and information dissemination regarding the topic. Emphasizing importance of adequate rest and exercise and a healthy diet is also advised to lessen incidence of acquiring the disease. Further health teachings should be given and made aware to all the benefactors of the said agency. Additional readable article that can be seen and appreciated by the public regarding infection spread control would be very useful. To future researchers The researcher therefore recommends that for all future researchers, they must have to deal with the early detection, prevention, and faster remedies of the disease. Never take for granted the time that you have to evaluate your client. The future researchers would appreciate the significance of having this case study by learning more of the clients disease. In data gathering, do not forget to apply your learning in infection control.