cÊ c


Dengue fever is found mostly during and shortly after the rainy season in tropical
and subtropical areas of

ÚÊ dfrica
ÚÊ {outheast dsia and China
ÚÊ cndia
ÚÊ ©iddle East
ÚÊ Caribbean and Central and {outh dmerica
ÚÊ dustralia and the {outh and Central Pacific

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

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

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

{ymptoms 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

ÚÊ High fever, up to 105 degrees Fahrenheit

ÚÊ {evere headache
ÚÊ ÿetro-orbital (behind the eye) pain
ÚÊ {evere joint and muscle pain
ÚÊ Nausea and vomiting
ÚÊ ÿash

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. {ymptoms of dengue hemorrhagic fever
include all of the symptoms of classic dengue plus

ÚÊ ©arked damage to blood and lymph vessels

ÚÊ -leeding from the nose, gums, or under the skin, causing purplish bruises

This form of dengue disease can cause death.

{ymptoms of dengue shock syndrome-the most severe form of dengue disease-

include all of the symptoms of classic dengue and dengue hemorrhagic fever, plus

ÚÊ Fluids leaking outside of blood vessels

ÚÊ ©assive bleeding
ÚÊ {hock (very low blood pressure)

This form of the disease usually occurs in children (sometimes adults)

experiencing their second dengue infection. ct is sometimes fatal, especially in children
and young adults.

r


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

 

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

Dengue fever is an infectious disease carried by mosquitoes and caused by any of

four related dengue viruses. This disease used to be called ³break-bone´ fever because it
sometimes causes severe joint and muscle pain that feels like bones are breaking, hence
the name. Health experts have known about dengue fever for more than 200 years.
cc.Ê Objective

Name: Denver Dumanas

dge: 16

Date of birth: 12-04-1995

dddress: -akun -angued

Gender: ©ale

ÿeligion: ÿoman Catholic

Civil {tatus: {ingle

Citizenship: Filipino

Hospital: clocos {ur Training ÿegional ©edical Center

Hospital Ward: Pediatric Ward

Physician:

Chief Complaint: {kin ÿashes

Diagnosis: Dengue

Date of ddmission: January 24, 2011

ccc.Ê History of cllness

Past history

The patient has been hospitalized in bakun district hospital for a high grade fever
and stayed at the hospital for two weeks. Upon few days of stay in the hospital the
patient had developed rashes on his entire body, her sister asked the staffs of the
hospital why does this rashes appeared on his brothers body. -ut the hospital wont
anticipate her sisters concerns and decided to transfer his brother to cTÿ©C.

Present History

©y patient was admitted at cT©ÿC January 24 2011 at 9:45pm due to skin rashes
and was diagnosed of dengue hemorrhagic fever.

Family Hstory
They don¶t have any hereditary diseases like diabetes, hypertension, tuberculosis,
cancer and other hereditary diseases.
c .Ê Physical dssessment

Findings {ignificance

General dppearance {light weak in appearance Due to dehydration and

body weakness

Head Normal head Normal

circumference

Face {ymmetrical movement Normal

Eyes No discharge, black pupil, Normal

dilated

Ears No wax, or discharges Normal

Nose No discharge Normal

Neck No lesions Normal

Lips {lightly dry Due to dehydration

Throat Not enlarged Normal

{kin With rashes Not normal, rashes on skin

of dengue pt¶s appears
after 3 to 4 days

Chest Normal Normal

Nails Pale in color Poor circulation

Upper and lower Well active no edema thin normal

extremities extremities
 .Ê dnatomy and Physiology

  
The blood consists of cells and cell fragments, called   
, and water
with dissolved molecules, called blood plasma



  


  

À
 
 

 (98±99%) anucleate, contain hemoglobin; O2 & CO2 transport

 
   granulocytes, polymorphonuclear; phagocytosis,
 : Neutrophils (60±70%) wound healing
Eosinophils (2±4%) granulocytes, bilobed nucleus; phagocytosis
-asophils (0.5±1%) granulocytes, 2 to 5 lobed nucleus; release histamine
Lymphocytes (20±25%) agranulocytes, circular nucleus, T cells, - cells;
immune response, antibodies
©onocytes (3±8%) agranulocytes, large kidneyshaped nucleus;
phagocytotic macrophages
 
    anucleate, megakaryocyte fragments; blood clotting
! 
  
   (8%): dlbumin (54%) maintain osmotic pressure between blood & tissues
Globulins (38%) lipid and metal ion transporters, antibodies
Fibrinogen (7%) clotting factor
Others (1%) enzymes, hormones, clotting factors
À 
! Na+, K+, Ca2+, ©g2+, Cc
, HCO3
, {O42
, HPO42

": O2, CO2, N2
#  :
Glucose, other carbohydrates sources of energy
dmino acids protein-building blocks
Lipids fats, steroids, phospholipids
Cholesterol component of plasma membranes & steroid
hormones
 
:
Urea from breakdown of proteins
Creatinine from breakdown of creatine phosphate (from
muscles)
Uric acid from breakdown of nucleic acids
-ilirubin from breakdown of hemoglobin
$  ! arious
"" 
Erythrocytes, or  #  $  % transport oxygen (O2) and carbon
dioxide (CO2) in the blood. Erythrocytes contain the protein hemoglobin to which both
O2 and CO2 attach.

©ature erythrocytes lack a nucleus and most cellular organelles, thereby

maximizing the cell's volume and thus its ability to carry hemoglobin and to transport O2.

Erythrocytes are shaped like flattened donuts with a depressed center (rather than
a donut hole). Their flattened shape maximizes surface area for the exchange of O2 and
CO2 and allows flexibility that permits their passage through narrow capillaries.

Hemoglobin contains both a protein portion, called globin, and nonprotein heme
groups. Globin consists of four polypeptide chains, each of which contains a heme group.
The heme group is a red pigment that contains a single iron atom surrounded by a ring of
nitrogen-containing carbon rings. One oxygen atom attaches to the iron of each heme
group, allowing a single hemoglobin molecule to carry four oxygen atoms. Each
erythrocyte contains about 250 million hemoglobin molecules.

Oxyhemoglobin (HbO2) forms in the lungs when erythrocytes are exposed to

oxygen as they pass through the lungs. Deoxyhemoglobin (Hb) forms when oxygen
detaches form the iron and diffuses into surrounding tissues.

Carbaminohemoglobin (HbCO2) forms when CO2 attaches to amino acids of the

globin part of the hemoglobin molecule. dbout 25 percent of the CO2 transported from
tissues to lungs is in this form.

Carbonic anhydrase, an enzyme in erythrocytes, converts CO2 and H2O in the

blood plasma to H+ and HCO3
dbout 65% of the CO2 collected from tissues travels in
the blood plasma as HCO3
.

-ecause they lack cellular organelles and thus physiology to maintain themselves,
erythrocytes survive for only about 120 days. Degenerated erythrocytes are broken down
in the spleen and liver by macrophages (phagocytic white blood cells) as follows:

1.Ê The globin and heme parts of the hemoglobin are separated. The globin is reduced to
amino acids, which are returned to the blood plasma.
2.Ê cron is removed from the heme group and bound to the proteins ferritin and
hemosiderin, which store the iron for later use (because unbound iron is toxic). cron is
also attached to transferrin, which enters the bloodstream. Transferrin may be picked
up by muscles or liver cells, where it may be stored as ferritin or hemosiderin or
picked up by bone marrow, where the iron is used to produce new erythrocytes.
3.Ê The remainder of the heme group is broken down into bilirubin (a yellow-orange
pigment), which enters the bloodstream and is picked up by the liver. Liver cells
incorporate bilirubin into bile, which enters the small intestine during the digestion of
fats. -ilirubin is then converted into urobilinogen by intestinal bacteria. Finally, most
urobilinogen is converted to the brown pigment stercobilin, which is eliminated with
the feces (and which gives feces its brown color). d small amount of urobilinogen is
absorbed into the blood, converted to the yellow pigment urobilin, picked up by the
kidneys, and eliminated with the urine (contributing to the yellow color of urine).

* &" 
Leukocytes, or ' #  (  , are cells that protect the body from
foreign microbes and toxins. dlthough all leukocytes can be found in the
 bloodstream, some permanently leave the bloodstream to enter tissues where they
encounter microbes or toxins, while other kinds of leukocytes readily move in and out
of the bloodstream. Leukocytes are classified into two groups, granulocytes and
agranulocytes, based upon the presence or absence of granules in the cytoplasm and
the shape of the nucleus.

ÚÊ Granulocytes contain numerous granules in the cytoplasm and have a nucleus that is
irregularly shaped with lobes. Each of the three types of granulocytes is named after
the bloodstains that its granules absorb.
ÚÊ Neutrophils, the most numerous of granulocytes, have an {- or Cshaped nucleus with
three to six lobes. Their granules, which are small and inconspicuous, poorly absorb
both basic and acidic stains (neutral pH preference), producing a pale, lilac color.
-ecause the shape of the nucleus is so variable, neutrophils are referred to as
polymorphonuclear leukocytes (P©Ns), or polys. Young neutrophils, with immature
nuclei that are shaped like rods, are called band neutrophils. Neutrophils are the first
leukocytes to arrive at a site of infection, responding (by chemotaxis) to chemicals
released by damaged cells. The neutrophils, by phagocytosis, actively engulf bacteria,
which are then destroyed by the various antibiotic proteins (such as defensins and
lysozymes) contained within the granules. The neutrophils, usually destroyed in the
process, contribute, together with other dead tissue, to the formation of pus.
ÚÊ Eosinophils have a bilobed nucleus (two lobes connected by a narrow strand of
chromatin). Their granules, which stain red with acid (eosin) dyes, contain digestive
enzymes and are considered lysosomes. Eosinophils actively phagocytize complexes
formed by the action of antibodies on antigens (foreign substances). Numbers of
eosinophils increase during parasitic infection and allergic reactions.
ÚÊ -asophils have a U- or {-shaped nucleus with two to five lobes connected by a
narrow strand of chromatin. Their granules, which stain blue-purple with basic dyes,
contain histamine, serotonin, and heparin. -asophils release histamine in response to
tissue damage and to pathogen invasion (as part of the inflammatory response).
-asophils resemble mast cells, cells similar in appearance and function to basophils,
but found only in connective tissues.
ÚÊ dgranulocytes, the second group of leukocytes, do not have visible granules in the
cytoplasm and the nucleus is not lobed. There are two types of these leukocytes:
ÚÊ Lymphocytes, often classified as small, medium, and large, have a roughly round
nucleus surrounded by a small amount of blue-staining cytoplasm. Lymphocytes are
the only leukocytes that return to the bloodstream, circulating among the
bloodstream, tissue fluids, tissues, and lymph fluid. There are two major groups of
lymphocytes, which vary based upon their role in an immune response. T
lymphocytes (T cells), which mature in the thymus gland, attack aberrant cells (such
as tumor cells, organ transplant cells, or cells infected by viruses). - lymphocytes (-
cells), which mature in the bone marrow, respond to circulating antigens (such as
toxins, viruses, or bacteria) by dividing to produce plasma cells, which in turn,
produce antibodies.
ÚÊ ©onocytes have a large, kidney-shaped nucleus surrounded by ample blue-gray-
staining cytoplasm. When monocytes leave the bloodstream and move into tissues,
they enlarge and become macrophages, which engulf microbes and cellular debris.

!  
!  #"  are fragments of huge cells called megakaryocytes.
Platelets lack a nucleus and consists of cytoplasm (with few organelles) surrounded by a
plasma membrane. Platelets adhere to damaged blood vessel walls and release enzymes
that activate  , the stoppage of bleeding.

! 
 !  is the straw-colored, liquid portion of the blood. ct consists of the following:

ÚÊ Water (90 percent).

ÚÊ Proteins (8 percent). dlbumin, the most common protein, is produced by the liver and
serves to preserve osmotic pressure between blood and tissues. Other proteins include
alpha and beta globulins (proteins that transport lipids and metal ions), gamma
globulins (antibodies), fibrinogen and prothrombin (clotting proteins), and hormones.
ÚÊ Waste products (urea, uric acid, creatinine, bilirubin, and others).
ÚÊ Nutrients (absorbed from the digestive tract).
ÚÊ Electrolytes (various ions such as sodium, calcium, chloride, and bicarbonate).
ÚÊ ÿespiratory gases (O2 and CO2).

{erum is the liquid material remaining after blood-clotting proteins have been
removed from plasma as a result of clotting.

c.Ê Laboratory Examinations

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