1. Pamantasan ng Lungsod ng Marikina
J.P. Rizal St. Concepcion Uno, Marikina City
__________________________
DENGUE FEVER
__________________________
An Individual Case Study
In Partial Fulfillment
of the Requirement for the Course
NCM 101
RLE
St. Victoria Hospital
Submitted by:
2. TABLE OF CONTENTS
I.
Introduction………………………………………
……….…………………
II.
1
Objectives with specific
objectives……………………….…………….
3
•
General Objective
•
Specific Objective
III.
Theoretical Foundation (Nursing theory)
………………………………
IV.
4
Nursing History……………………………………………….……………
5
a. Biographical Data
b. Reason for seeking health care
c. History of present illness
d. Past health History
e. Family genogram……………………………………………………………
6
f. Social History
V.
Immunization/Exposure to communicable
disease…………………
7
VI.
Allergies
VII.
Home Medication/ Alternative medicine
VIII.
Developmental Level
5. I.
Introduction
Dengue is one of the most common mosquito-borne viral diseases. The first and
second epidemics of Dengue hemorrhagic fever occurred in Manila in 1954 and 1956,
followed by the third in Bangkok in 1958. Since then, Dengue has spread throughout
tropical Asian countries and has expanded globally. Dengue virus belongs to the
flavivirus genus of the Flaviviridae family. They are transmitted among humans by
Aedes mosquitoes bite such as Aedes aegypti. There are four serotypes, namely
Dengue type 1, Dengue type 2, Dengue type 3 and Dengue type 4. Infection with any of
the four serotypes causes clinical symptoms that may vary in virus virulence, and host
response. And recovery from one infection provides life- long immunity against that
particular serotype. Dengue has its progression from Dengue fever, which is a simple
form of dengue it may lead to dengue hemorrhagic fever, a condition which involves
sensitive stomach, petechial, weak pulse, and internal bleeding that can lead to black
vomit or feces. If dengue hemorrhagic fever is untreated it may progress to dengue
shock syndrome, a worst form of dengue which can also result to death.
According to World Health Organization (WHO), each year an estimated 100
million cases of dengue occur worldwide, about 2.5 billion people living in tropical and
subtropical areas are at risk. The National Epidemiology Center of the Philippines'
Department of Health reports a total of 132,046 dengue cases from January to 13
October 2012. This is 24.92% higher compared to the same time period in 2011. Region
III and Region IV-A registered the highest number of cases, about 30% of these cases,
may progress to dengue hemorrhagic fever or dengue shock syndrome and an
estimated 10% will eventually lead to death. The global prevalence of dengue has
grown dramatically in recent decades. The disease is now endemic in 100 countries of
Africa, the Americas, the Eastern Mediterranean, Southeast Asia and the Western
Pacific.
There is no specific treatment for dengue fever, dengue hemorrhagic fever, and
dengue shock syndrome but this can be treated by timely supportive therapy to
undertake circulatory shock due to hemoconcentration (plasma leakage) and bleeding.
1
6. Close observation of vital signs by the attending physician and nurses with frequent
clinical and laboratory monitoring especially in critical point. Adequate fluid replacement
is also necessary to overcome the plasma leakage. Intravenous infusion is also helpful
to rehydrate especially if the patient is not able to maintain oral intake. For reducing
fever, frequent tepid sponge bath and paracetamol are provided. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are contraindicated
because these may worsen the bleeding tendency and might cause some infections.
Acetaminophen and paracetamol can be taken under the prescription of the doctor.
I chose these case because I was motivated to study this globally common,
yearly problem of most of the country in Asia. By this, I will be able to discover its
process, how it is being acquired, the pathophysiology and clinical manifestations which
are being experienced by my patient. By doing so, I am able to fructify my knowledge,
enabling me to know the appropriate nursing care for my patient. This study would help
me as a student nurse to comprehend not only the disease mentioned but also for the
commonalities and differences among other diseases for the betterment of this study.
2
7. II. Objectives with specific objectives
General Objective:
At the end of the study, the student will be able to improve not only the knowledge
in the disease process and clinical manifestations but also on how to give necessary
intervention indicated to the patient. By this, we will be able to hasten our knowledge,
skills, and attitude in giving appropriate nursing care for the patient. Through thorough
research and interview, we can acquire concrete and necessary information about
Dengue Fever.
Specific Objectives:
1. To establish rapport with my client and her significant others to gain good
working relationship for the success of this case study.
2. Present reasonable introduction that will provide an overview of the disease and
can be an eye-opener of information for the readers.
3. Conduct thorough physical assessment of the patient in cephalocaudal manner
to note other problems of the patient to be managed.
4. Discuss the anatomy and physiology of the affected system to have a
background regarding the organ affected by the disease.
5. Provide necessary nursing care plan to prioritize the immediate problem of the
patient.
6. Provide comprehensive discharge plan of the patient to ensure the continuation
of the management of the disease even after discharge.
3
8. III.
Theoretical Foundation (1) Nursing theory
According to Florence Nightingale’s Environmental theory, ventilation is
important because a person who breathes his own air repeatedly would become
sick. She also said that we should maintain cleanliness because it is important in
quick recovery of the patient. Effective drainage is also necessary because this
will help in preventing the breeding of the epidemic diseases. And pure water is
also important because when epidemic disease shows itself, safe water is
needed to avoid infection and to ensure your health safety. The case of DG can
be associated with Florence Nightingale theory, wherein, clean environment
plays an important role in rejuvenating the patient’s optimum level of health.
According to the mother, they have uncovered stocked water outside their house
and due to continuous raining they’ve suspected that it is one of the reasons why
her daughter got the disease. Having a clean, quiet, and well- ventilated
environment, also an effective drainage and pure water will help the body to
restore more quickly.
4
9. IV. Nursing History
A. Biographical Data
This is a case study of DG, a 6 years old girl who lives in Guitnang Bayan,
San Mateo Rizal. Her mother is a Grade 4 teacher in San Mateo Elementary
School. She was born in Quezon City on the date of August 30, 2007. Her parents
are the ones who supported her in hospital bills. Her mother is the one who
brought her to the hospital last September 2, 2013 @6pm under the supervision of
Dra.Ordonez.
B. Reason for seeking Health Care
She was experiencing intermittent fever of 39 0C for the past 3 days so her
mother decided to take her to the hospital for check-up.
C. History of Present Illness
According to the mother, three days prior to admission, her daughter had a
positive intermittent fever of 390C. What she did was to self-medicate her daughter
with paracetamol for three consecutive days, but the patient was still having fever
which led them to the hospital for check- up with Dra. Ordonez who had also
advised them to have patient admitted.
D. Past Health History (PHH)
My patient had pneumonia when she was two years old and had been
admitted and stayed to the hospital for 1 and a half month. As far as the mother
recalled, her daughter took medicine like amoxicillin.
5
10. E. Family Genogram
FATHER SIDE
FATHER SIDE
MOTHER SIDE
MOTHER SIDE
Lolo (63)
Lola (60)
HPN
Lolo (62)
HPN
A&W
A&W
A&W
34 y/o
33y/o
32y/o
A&W
31y/o
A&W
30y/o
Lola (59)
DM
A&W
29y/o
DM
A&W
A&W
33y/o
35y/o
Patient DG
Legend:
Female
Male
Alive and well Female
Alive and well Male
Unhealthy Female
Unhealthy Male
F. Social History
Patient DG is the only Child of Ms.AG. She is in her school age. Patient
DG loves to play computer games at home; she does her homework first before
playing games. According to her mother she sometimes plays outside their
house with her friends.
6
11. V. Immunization/ Exposure to communicable Disease
Patient DG had completed her immunization when she was a child. She
received DPT, OPV, Hepatitis vaccine, Anti-measles vaccine and BCG from the
Barangay health center. She did have pneumonia when she was 2 years old.
VI. Allergies
Patient DG doesn’t have any allergies to any food, dust, drugs or
anything according to the mother.
VII. Home Medications/Alternative Medicine
According to the mother when her daughter catches up cold and cough
she usually gave her herbal medicine like oregano juice with calamansi extract,
and it is effective to her. For fever, she usually gave paracetamol.
VIII. Developmental Level
Patient DG is in her School-age level (6-12 y/o). According to Erik
Erickson (Psychosocial theory), patient DG’s developmental task is to form a
sense of industry vs. inferiority. Child learns to do things well. Patient DG was
able to write her name correctly, she can also read paragraphs. According to her
mother she allows patient DG to do her homework on her own, and when patient
DG is done with it, she allows her to play computer games for her reward.
7
12. IX.
Pediatric History
a. Developmental Milestone
According to Maternal and child nursing care book, Lippincott
William and Wilkins, volume two, pp 915, a school- age person treats her
teacher as the authority; adjustment to all-day school may be difficult and
lead to nervous manifestations of fingernail biting. Also, a six years old
child can walk on a straight line because they have enough coordination.
Patient DG was able to show industry instead of inferiority especially in
doing school works. She can easily tie her shoelaces, read, and write.
According to her mother, she can also shade coloring books with minimal
error, can fold and cut paper into simple shapes.
8
13. XII. Gordon’s Functional Pattern
BEFORE
DURING
PATTERN
HOSPITALIZATION
Dati po masigla ako,
HOSPITALIZATION
Di na po ako
ANALYSIS
Due to her illness
Health Perception
pumapasok sa school
makapasok sa school
at naglalaro ng
kasi may sakit ako
computer games
She eats 3x a day,
Mostly eat bread and
The doctor ordered
Nutritional
loves to eat processed
fruits. She drinks 6-8
diet as tolerated
Metabolic
foods such as tocino,
glasses of water a day.
(DAT) to the patient
meatloft, hotdog. She
and except dark
seldom eats
colored food (EDCF)
vegetables and drinks
6-8 glasses of water.
She is able to urinate
Her condition doesn’t
(3x a day) and
(3x a day) and defecate
affect her elimination
defecate (1x a day)
(1x a day) normally
pattern.
normally every day.
Elimination
She is able to urinate
every day.
She usually defecate
early in the morning
before going to school
without any problem
Her daily routine is
She only focuses on
going to school, doing
auntie, mother and
simple things.
home works then
Activity/Exercise
She interacts with her
visitors.
playing computer
Sleep/Rest
games
Matagal po ang tulog
Nagigising po ako
This may be due to
Cognitive/
ko, minsan 8-9 hours
There is no problem in
minsan.
There is no problem in
giving of medication.
Adjusting to
Perceptual
her senses.
her senses. She is
environment
She can comprehend
responsive but shy
well. Responses to
12
physical and verbal
when asked.
14. She is the only child
Due to her condition
and source of joy and
Role-Relationship
stimuli
She is the only child
and source of joy and
she can’t perform her
strength of her parents. strength of her parents.
role in her parents.
But also stress because
she is sick.
Same
Sexuality-
She doesn’t fully
Due to her youthful
Reproductive
understand about
mind, it is still not her
having a
priority in life.
Coping/Stress
boyfriend/married
She doesn’t fully
Tolerance
identify stressors
mind and doesn’t
Values/Beliefs
She is a Born-Again
mind stressors of life.
Due to parents
Christian. She goes to
influence
Same
She is still in a playful
church every Sunday
13
15. XIII. Physical Assessment
Name: DG
Age: 6y/o
Date of assessment: Sept. 6, 2013
BODY PARTS
Skin
NORMAL FINDINGS
Uniform color, except
ACTUAL FINDINGS
Equal distribution of color,
ANALYSIS
Rash may be due to
in the areas exposed
no lesions, (-) turgor, rash
increase of blood
to the sun, no edema
present in in right foot.
pressure in the
present and no other
vessel.
Hair is black in color, no
evidence of alopecia,
and no presence of
evenly distributed hair, (-)
dandruff, silky and
pediculosis and dandruff
resilient hair.
Rounded, smooth skull
There is no
contour, absences of
lumps/masses, no lesions,
nodules and masses;
Head/Scalp
lesions
Evenly distributed hair,
thick hair, no infection,
Hair
smooth skull contour
Normal findings
Normal findings
has systematic facial
features and
movements.
Eyebrows and
Eye brows and eye lashes
Eyelashes are evenly
are evenly distributed,
distributed, the eyelids
eyes are dark brown in
has no discharge and
color, Sclera is white in
no discoloration; pupils
color, (+) light
are black in color;
accommodation, pupils
round, equal in size
are black in color and
normally 3-7 mm in
equal in size, no lesions or
diameter; conjunctiva
discharge in conjunctiva
pink in color, the sclera
Eyes
and is pink in color
Normal findings
14 white in color.
are
Ears
Color same as facial
Color same as facial skin,
Normal findings
16. skin, symmetrical,
symmetrical auricle
auricle aligned with
alignment with outer
outer cantus of eyes
cantus of eyes. (+) ear
about 10º from vertical, wax, pinna recoils after it
not tender; pinna
is folded and able to hear
recoils after it is folded
sound in both ears.
able to hear sound in
No discharge, symmetrical
and straight alignment,
uniform color. No
uniform in color. No
tenderness and no
tenderness and lesions
lesions.
Lips pink in color, soft,
(-) dryness, teeth are
moist, smooth texture,
intact, no inflammation in
ability to purse lips; the
uvula and tonsil, tongue is
teeth are smooth,
Lips/Mouth
both ears.
Symmetric and straight
no discharge or flaring,
Nose
in central position
Normal findings
Normal findings
white, firm texture to
the gums. Tongue is in
central position, pink in
color moist.
Muscle equal in size;
Uniform in color, no
head centered; head
lumps/masses, no pain
movement is
when swallowing, head
coordinated and in
Neck
centered
Normal findings
smooth movement. No
Chest
enlarge lymph node.
Quiet, rhythmic
No retractions when
respiration, normal
breathing, no use of
breathing rate, no
accessory muscle used
15
retraction when
when breathing,
breathing
symmetrical chest
movement
Normal findings
17. Abdomen
Uniform color, no
Uniform in color, skin
evidence of enlarged
intact, soft, no tenderness,
liver or spleen. Audible
Normal findings
(+) borborygmi sound.
bowel sounds,
absence at arterial
bruits, and absence at
friction rubs, no
Extremities
tenderness.
Convex curvature,
Uniform in color, no
Rash may be due to
angle of nail plate
fractures, symmetrical in
increase of blood
160º, smooth texture,
movement, has some rash
pressure in the
when performing the
in right foot, nail beds are
vessel.
blanch test of capillary
pink in color, capillary
refill it is prompt return
refills at 2-3 seconds
of usual color. (2-3
sec)
16
18. XIV. Diagnostic/Laboratory Examination
Physician: Dr. Chanyungco
Examination
Normal
Actual
Values
Findings
5.0-10.0x109/L
3.0
Date: Sept. 2, 2013
Significance
Hematology
Report
WBC
Decrease due to inadequate
inflammatory response defense to
suppress infection and anti-body
RBC
4.2-5.6x1012/L
4.8
mediated immunity takes place.
Normal
Hemoglobin
140-180g/L
130
Decreased hemoglobin results in RBC
destruction or infiltration of bone marrow
Hematocrit
0.37-0.47
0.41
with the infectious cell.
Normal
Platelet
150-400x109/L
167
Normal
0.40-0.60
0.85
Increased due to infection, it attack and
0.13
kill infections
Decreased due to debilitating illness,
0.02-0.05
0.02
humoral immune response to take place.
Normal
125-160g/dl
120
WBC Differential
Count
Segmenters
Lymphocytes
Monocytes
0.20-0.40
CBC with Platelet
Hemoglobin
Decreased hemoglobin results in RBC
destruction or infiltration of bone marrow
Hematocrit
0.38-0.54
0.37
with the infectious cell.
Decreased results in RBC destruction or
infiltration of bone marrow with the
WBC
9
4.5-10.0x10 /L
1.70
17
infectious cell.
Decrease due to inadequate inflammatory
response defense to suppress infection
and anti-body mediated immunity takes
19. 4.2-6.2x10 /L
4.20
place.
Normal
0.46-0.66
0.33
Decreased due to inadequate protection to
12
RBC
WBC Differential
Count
Segmenters
an ongoing infection because it acts as
phagocytes and first to arrive in infected
site.
Lymphocytes
0.20-0.40
0.70
Decreased due to debilitating illness,
Platelet
150-400x109/L
229
humoral immune response to take place.
Normal
Leah Tolentino
Alsol, Mennen
Med. Tech
Pathologist
Lab Result
Examination:
Dengue NS1
Significance
Specimen:
Blood
Dengue NS1 an antigen tests (NS1 stands for
Dengue NS1:
Positive (+)
nonstructural protein 1), full name is Platelia Dengue
NS1 Ag assay, is a test for dengue. It allows rapid
detection on the first day of fever, before antibodies
appear some 5 or more days later.
Clinical Result
Date: Sept. 3, 2013
Urinalysis
Color
Normal findings
Normal urine is a transparent
Actual findings
Yellow
Analysis
Normal findings
solution ranging from colorless
to amber but is usually a pale
Transparency
yellow.
The turbidity of the urine sample
18
is clear, slightly cloud, cloudy,
opaque. Normally, fresh urine is
slightly cloudy.
Slightly turbid
Normal findings
20. Specific Gravity Normal urine density or values
1.030
Normal findings
(6) Acidic
Acidic pH helps in
vary between 1.003–1.035
(g·cm−3)
The pH of urine can vary
pH
between 4.6 and 8, with neutral
(7) being norm
WBC
RBC
preventing bacterial
growth
6-8/HPF
0.2/hpf
Presence of
1-3/HPF
0.2/hpf
infection
May be due to
bladder problem
Bacteria
Absent
Moderate
Presence of
infection
Epithelial Cells
Absent
few
Possible
contamination of the
specimen
E
Examination
Normal
Actual
Values
Significance
Findings
CBC with Platelet
Hemoglobin
Hematocrit
WBC
125-160g/dl
130
0.38-0.54
0.40
9
4.5-10.0x10 /L 2.5
Normal
Normal
Decrease due to inadequate
inflammatory response defense to
suppress infection and anti-body
12
RBC
WBC Differential
4.2-6.2x10 /L
Normal
Count
Segmenters
Values
0.46-0.66
4.55
Actual
mediated immunity takes place.
Normal
Significance
Findings
0.38
Decreased due to inadequate
19
protection to an ongoing infection
because it acts as phagocytes and
first to arrive in infected site.
Lymphocytes
0.20-0.40
0.62
Increase immune response fighting
infection
21. 150-400x109/L 175
Platelet
Normal
Date: Sept. 4, 2013
E
Examination
Normal
Actual
Values
Significance
Findings
CBC with Platelet
Hemoglobin
Hematocrit
WBC
125-160g/dl
130
0.38-0.54
0.40
9
4.5-10.0x10 /L 1.80
Normal
Normal
Decrease due to inadequate
inflammatory response defense to
suppress infection and anti-body
Count
Segmenters
Lymphocytes
4.2-6.2x10 /L
4.55
0.46-0.66
0.20-0.40
RBC
WBC Differential
mediated immunity takes place.
Normal
0.42
0.58
Normal
Increase immune response fighting
12
9
Platelet
150-400x10 /L 178
Clinical Result
infection
Normal
20
Date: Sept. 5, 2013
Urinalysis
Urinalysis
Color
Normal findings
Normal urine is a transparent
Actual Findings
Yellow
Analysis
Normal findings
Clear
Normal findings
Specific
fresh urine is slightly cloudy.
Normal urine density or values 1.005
Normal findings
Gravity
vary between 1.003–1.035
pH
(g·cm−3)
The pH of urine can vary
solution ranging from
colorless to amber but is
Transparency
usually a pale yellow.
The turbidity of the urine
sample is clear, slightly cloud,
cloudy, opaque. Normally,
(6)Acidic
Acidic pH helps in
22. between 4.6 and 8, with
preventing bacterial
neutral (7) being norm
growth
WBC
0.2/hpf
1-2/HPF
Presence of infection
RBC
0.2/hpf
0-3/HPF
May be due to
bladder problem
Bacteria
Few
Presence of infection
Epithelial Cells
E
Absent
Absent
Few
Possible
contamination of the
specimen
Examination
Normal
Actual
Significance
Values
Findings
Hemoglobin
125-160g/dl
116
Decreased hemoglobin results in RBC
destruction or infiltration of bone marrow
with the infectious cell.
Hematocrit
0.38-0.54
0.36
21
Decreased results in RBC destruction or
infiltration of bone marrow with the
infectious cell.
WBC
4.5-10.0x109/L 1.1
CBC with Platelet
Decrease due to inadequate inflammatory
response defense to suppress infection
and anti-body mediated immunity takes
RBC
12
4.2-6.2x10 /L
4.06
place.
Decreased due to destruction of RBC or
infiltration of bone marrow with infectious
cell
WBC Differential
Count
Segmenters
0.46-0.66
0.37
Decreased due to inadequate protection
to an ongoing infection because it acts as
phagocytes and first to arrive in infected
site.
Lymphocytes
0.20-0.40
0.63
Increase immune response fighting
23. 9
Platelet
150-400x10 /L 211
infection
Normal
Clinical Result
Serology for typhidot
IgM (-)
IgG(-)
Clinical Interpretation
Results
IgM (+)
IgM &IgG (+)
IgG (+)
Clinical Interpretation
Acute typhoid fever
Acute typhoid fever (in the middle stage of infection)
Implication for the presence of IgG antibodies infection (in which case
IgM & IgG (-)
current fever may not be due to typhoid)
Probably not typhoid
Date: Sept. 6, 2013 @9am
E
Examination
Normal
Actual
Significance
Values
Findings
Hemoglobin
125-160g/dl
120
Decreased hemoglobin results in RBC
destruction or infiltration of bone marrow
with the infectious cell.
Hematocrit
0.38-0.54
0.37
Decreased results in RBC destruction or
infiltration of bone marrow with the
infectious cell.
WBC
4.5-10.0x109/L 2.10
CBC with Platelet
Decrease due to inadequate inflammatory
response defense to suppress infection and
RBC
WBC
Differential Count
Segmenters
4.2-6.2x10 /L
4.20
anti-body mediated immunity takes place.
Normal
0.46-0.66
0.40
Decreased due to inadequate protection to
12
an ongoing infection because it acts as
phagocytes and first to arrive in infected
site.
Lymphocytes
0.20-0.40
0.60
increase due to increase immune response
25. XVIII. Discharge Plan (use METHODS format)
M-edicine
•
Advise the relatives to continue the prescribed
home medications to ensure optimum recovery.
Use screens or mosquito nets when sleeping
Do not stock water without cover to avoid
•
mosquito breeding.
Instruct patient or parents to increase fluid intake
•
Instruct patient or parents to have complete bed
•
rest
Advise the parents to use insect repellants
•
H-ealth Education
Provide a clean environment
•
T-reatment
•
•
E-xercise
Use also insecticides in the house once in a
month
O-ut patient Dep’t
(Check-up)
D-iet
•
•
Maintain good hygiene by taking a daily bath
Instruct patient to continue follow-up check up to
•
the doctor.
Eat healthy foods such as fruits, vegetables, and
meat
•
Drink a lot of water, at least 8-10 glasses of water
a day
S-pirituality
•
Advise patient to maintain good and safe
environment
31
