I.

Introduction:
Dengue fever is an acute illness of sudden onset that usually follows a benign course with fever, headache, rashes, and severe muscle pain, frequently accompanied by sore throat, dizziness and loss of appetite, vomiting and diarrhea. It is caused by a bite of striped Aedes aegypti and Aedes albopictus mosquito which has previously bitten an infected person. This type of mosquito spreads during rainy days/ seasons but can breed all year round in standing water, in flower pots, plastic bags, tires and cans. Dengue strikes people with low levels of immunity. Although the virus is not contagious and cannot be spread directly from person to person, it is possible to get dengue fever several times. When a person is infected, physical examination may show low blood pressure, skin rashes and sore throat, rapid pulse, swollen glands and enlarged liver. The signs to watch for are bleeding, blood spots in the skin, spotting of blood, and blood in the stool, gum bleeding and nose bleeding. The common complications of the disease are pneumonia and inflammation of the heart. There is no specific medicine or vaccine to treat dengue because it is caused by a virus. The treatment is to relieve the patient of the symptoms. To treat dehydration and electrolyte imbalance, IVF and electrolytes are necessary. Blood transfusions may be needed to control bleeding. Dengue fever can be caused by any one of four types of dengue virus: DEN1, 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. Majority of confined patients in the hospitals are diagnosed with dengue. In addition, we are currently experiencing a rainy season in our everyday living which increases the risks of being infected by mosquitoes that carries the virus. Numerous of our love ones and relatives have also been bitten by these mosquitoes which has drawn to our attention to create a detailed case study about dengue in order to educate ourselves on how to prevent being infected or how to treat its symptoms.

II. Objectives:
General

This case presentation aims to identify and determine the general health 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.

Specific:

To raise the level of awareness of patient on health problems that she may encounter. To facilitate patient in taking necessary actions to solve and prevent the identified problems on her own. To help patient in motivating her 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. 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.

iii. Health History Biographic Information

Cano, Lourdes 57 years old/ F / Filipina / Magao Cpn. Tarlac / 10 10 54 Date admitted: 7/4/11 10:00 am Diagnosis: Dengue Fever BP: 130/90 T: 37.1C Reasons for seeking health care Patient is experiencing symptoms of dengue fever. She is unable to perform the activities of daily living because of the virus that she has received from an infected mosquito.

Client Expectations Patient expects to fully recover from the virus by relieving her from the symptoms of Dengue fever. Expectations include elimination of nausea and vomiting, fever and complete recovery. Present Health History The present health history started 7 days ago prior to admission. The patient had a sudden onset of headache and an on and off fever; no medication and consultation to the doctor was done. Few days prior to admission, the patient had high grade fever at 37.1C accompanied with throbbing headache. She self-medicated with Paracetamol 500mg and afforded temporary relief. Due to persistence of the said signs and symptoms, the patient seeks consultation and hence admitted at Concepcion District Hospital. She was admitted last July 4 at around 10:20 am. Past Health History Prior to her hospitalization at Concepcion District Hospital, she denies in having any record or medical history of being admitted due to trauma, accident and disease. She also denies having allergies to food and drugs. She says that she is allergic to dust and particles.

OB History

Lourdes is a mother of 3 children; two boys in the age of 23 and 20 years old and a female in the age of 30. She had never had an abortion or miscarriage. All of her children were in full term. Family Health History No hereditary disease can be attributed from her father side, but her mother had a family health history of hypertension. Other than the latter, no other hereditary disease from both of his parents are within the patients knowledge Spiritual Health She is a catholic since birth and all other members of her family are of the same religion. She often attends worship services every Sunday. However she does not participate with any other religious activities that her religion has. She turns to god for answers and seeks aid when she is ill. Health Practices According to her, she eats moderately. She often eats fish and vegetables; she eats meat few times a week. She admits that she drinks plenty of water and gets herself well-hydrated. However, frequent exercises are not practiced. Lourdes does not smoke nor drink. Socio-Economic Background Being the eldest among six children, she considers herself as an active individual who is fond of interacting with other people. She considers herself as friendly even at home and at work.

Iv. Cephalo-caudal Assessment PHYSICAL ASSESSMENT Date assessed: July 9, 2011 General assessment: conscious and coherent

Initial vital signs: T=36.2 C, RR=23, BP=90/60, PR=70 Area Assessed Skin Color Technique Inspection Normal Findings Light brown, tanned skin (vary according to race) Lighter colored palms, soles Skin normally dry Normally warm Smooth and soft Skin snaps back immediately Actual Findings Light brown skin Evaluation Normal

Soles and palms Moisture Temperature Texture Turgor Skin appendages a. Nails Nail beds

Inspection Inspection/ Palpation Palpation Palpation Palpation

Lighter colored palms, soles Skin normally dry Normally warm Smooth and soft Skin snaps back immediately

Normal Normal Normal Normal Normal

Inspection Inspection

Transparent, smooth and convex Pinkish

Transparent, smooth and convex Pale

Normal Due to decreased blood flow Normal Normal

Nail base

Inspection

Capillary refill

Inspection/ Palpation

Firm White color of nail bed under pressure should return to pink within 2-3 seconds Evenly distributed Black Smooth

Firm Returns within 2-3 seconds

b. Hair Distribution Color Texture Eyes Eyes Visual Acuity

Inspection Inspection Inspection/ Palpation Inspection Inspection (penlight)

Evenly distributed Black Smooth

Normal Normal Normal

Eyebrows

Inspection

Eyelashes

Inspection

Parallel to each other PERRLA- Pupils equally round react to light and accommodation Symmetrical in size, extension, hair texture and movement Distributed evenly and curved outward

Parallel to each other PERRLA- Pupils equally round react to light and accommodation Symmetrical in size, extension, hair texture and movement Distributed evenly and curved outward

Normal Normal

Normal

Normal

Eyelids

Inspection

Same color as the skin

Same color as the skin

Normal

Blinks involuntarily Blinks involuntarily and bilaterally up to and bilaterally up to Normal 20 times per minute 18 times per minute Do not cover the pupil and the sclera, lids normally close symmetrically Transparent with light pink color Color is white Transparent, shiny Black, constrict briskly Clearly visible Free of lesions, discharge of inflammation Canal walls pink Client normally hears words when whispered Smooth, symmetric with same color as the face Oval, symmetric and without discharge Do not cover the pupil and the sclera, Normal lids normally close symmetrically Transparent with light pink color Color is white Transparent, shiny Black, constrict briskly Clearly visible Free of lesions, discharge of inflammation Canal walls pink Client normally hears words when whispered Smooth, symmetric with same color as the face Oval, symmetric and without discharge Normal Normal Normal Normal Normal Normal

Conjunctiva Sclera Cornea Pupils Iris Ears Ear canal opening

Inspection Inspection Inspection Inspection Inspection Inspection

Normal Normal

Hearing Acuity

Inspection

Nose Shape, size and skin color

Inspection

Normal

Nares

Inspection

Normal

Mouth and Pharynx Lips Buccal mucosa Gums

Inspection Inspection Inspection

Pink, moist symmetric Glistening pink soft moist Slightly pink color, moist and tightly fit

Light pink, dry, symmetric Glistening pink soft moist Slightly pink color, moist and tightly fit

Lack of fluid intake Normal

Normal

Tongue

Inspection

Teeth Hard and soft palate

Inspection Inspection

against each tooth Moist, slightly rough on dorsal surface medium or dull red Firmly set, shiny Hard palate- domeshaped Soft Palate- light pink Neck is slightly hyper extended, without masses or asymmetry Neck moves freely, without discomfort Rises freely with swallowing Clear breath sounds Skin same color with the rest of the body

against each tooth Moist, slightly rough on dorsal surface medium or dull red Firmly set, shiny With tooth decay Hard palate- domeshaped Soft Palate- light pink Neck is slightly hyper extended, without masses or asymmetry Neck moves freely, without discomfort Rises freely with swallowing Clear breath sounds Skin same color with the rest of the body

Normal

Normal

Normal

Neck Symmetry of neck muscles, alignment of trachea Neck ROM Thyroid gland Thorax and Lungs Abdomen

Inspection

Normal

Inspection Palpation Auscultation Inspection

Normal Normal Normal Normal

Bowel sounds

Auscultation Clicks or gurling sounds occur irregularly and range from 5-35 per minute Clicks or gurling sounds occur irregularly and range from 20 per minute

Normal

Extremities Symmetry Skin color Inspection Inspection Symmetrical Symmetrical Normal

Same with the color Same with the color Normal of other parts of the of other parts of the body body Evenly distributed Warm to touch Evenly distributed Warm to touch Normal Normal

Hair distribution Skin Temperature

Inspection Palpation

P r e s e n c e o f l e s i o n R O M Neurology system Level of consciousness

Inspection Inspection

No lesions Moves freely without discomfort

No lesions Able to move but with assistance

Normal Due to body weakness

Inspection

Fully conscious, respond to questions quickly, perceptive of events Makes eye contact with examiner, hyperactive expresses feelings with response to the situation

Fully conscious, respond to Normal questions quickly perceptive of events

Behavior and appearance

Inspection

Makes eye contact with examiner, hyperactive Normal expresses feelings with response to the situation

Review of Systems

Elimination

Her elimination pattern has somehow deviated from her usual urine and stool elimination. Before her confinement, she usually urinates for 7 times a day and defecates at least 2 times per day. During her confinement, she now urinates 5 times a day and defecates 3 times a day. According to her the variation from her elimination pattern is due to change in appetite and setting. In addition, blood in stool has been recognized.

Rest & Activity A typical day to her would be waking up at around 3:00 am to do her responsibilities such as cleaning the house. She had no time take naps in the afternoon but rather sleeps at around 11 oclock in the evening. During her confinement, she was able to rest and have enough sleep as well. During her leisure time before confinement, she usually reads magazines and newspaper Safety She usually stays home at her house. There is no physical threat for her safety. Unfortunately, the vector-borne disease affected her and almost cost her life. Oxygenation According to her, before and during her confinement she had no difficulty in breathing and ventilation.

V. Anatomy and Physiology Circulatory System

The circulatory system in humans is a network of blood vessels through which the heart pumps the blood and keeps the blood in circulation. The circulation system provides blood to each cell in the body. The circulatory system comprises of two sub systems cardiovascular system and the lymphatic system. The cardiovascular system consists of the heart, blood and the blood vessels in the form of arteries and veins. The lymphatic system consists of the lymph vessels, lymphatic nodes and lymph. There are two categories of blood vessels arteries and veins. The arteries carry the oxygenated blood from the heart to the rest of the body where it distributes the oxygen and nutrients. The veins carry the deoxygenated blood from the body organs back to the heart. The heart pushes the deoxygenated blood to the lungs, where the blood exchanges the carbon dioxide with fresh oxygen and is returned to the heart for recirculation to the body organs. When the blood reaches the intestines, it collects nutrients for distribution and discards the waste collected from the body cells to the intestines. The blood carries the oxygen and the nutrients to the tissues of the body where it exchanges them with carbon dioxide and waste from the cells. Waste like toxins are released into the kidneys. Another important role of blood is to carry the white blood platelets that have the capacity to fight germs and contain diseases to the infection areas. Therefore, blood helps the immune system of the body.

The Heart
The heart is a special involuntary muscle called the cardiac muscle. Involuntary muscles keep working on their own without our intervention or effort. The heart is divided into two sides

divided by the septum. Each side has two chambers a ventricle and an atrium. The left side of the heart is responsible for pumping the oxygenated blood from the lungs to the rest of the body. The right side of the heart is responsible for bringing the deoxygenated blood back to the lungs. The heart keeps beating rhythmically using an electrical signal from the sinoatrial node located at the top of the heart. An electrocardiograph machine can record these electric impulses to study the performance of the heart. The heart is a very important part of the circulatory system. If a part of the blood is lost, one can survive as the blood can get regenerated very quickly. However, any damage to the heart can be fatal. The heart is made up of involuntary cardiac muscles that keep the heart beating without any manual intervention as long as it remains healthy.

Blood Vessels
The cardiovascular system part of the circulatory system is a closed network of blood vessels through which the blood keeps circulating due to the action of the heart. The blood vessels that carry the oxygenated blood away from the heart to the body organs are called the arteries. The blood vessels that collect the deoxygenated blood and bring it back to the heart are called the veins. The blood vessels are thick near the heart and divide into smaller arteries and finally into capillaries that are only one cell layer thick. Just to compare, the largest arteries called the aorta and the largest vein called the vena cava are each about an inch in diameter.

Lymph
When the blood carries the nutrition to the individual cells and collects waste, it forms the interstitial fluid between the cells of a tissue to transfer the nutrients to the cells. The lymphatic system is a network of one way vessels that collect the interstitial fluid called lymph into the lymph vessels which push the lymph by rhythmic contractions through several lymph nodes on the way into the subclavian veins where the lymph mixes back with the blood.

Blood The blood is composed of fluid called plasma that contains red blood cells, white
blood cells and platelets. The plasma carries the proteins, hormones and minerals from one part of the body to the other. The red blood cells contain hemoglobin which helps to transport oxygen from the lungs to the rest of the body parts. The white blood cells help to fight

infections and diseases. The blood platelets help to clot after an injury thereby preventing an excess loss of blood.

Blood performs many important functions within the body including:

Supply of oxygen to tissues (bound to hemoglobin, which is carried in red cells) Supply of nutrients such as glucose, amino acids, and fatty acids (dissolved in the blood or bound to plasma proteins) Removal of waste such as carbon dioxide, urea, and lactic acid Immunological functions, including circulation of white blood cells, and detection of foreign material by antibodies Coagulation, which is one part of the body's self-repair mechanism Messenger functions, including the transport of hormones and the signaling of tissue damage Regulation of body pH (the normal pH of blood is in the range of 7.35 - 7.45) Regulation of core body temperature Hydraulic functions

vi. Pathophysiology NARRATIVE Dengue fever, a contagious disease transmitted by the Aedes aegypti mosquito, found in tropical and subtropical regions in the world. Dengue fever is transmitted only through an infected mosquito. When a patient is bitten by a virus carrying mosquito, the infectious virus is deposited in the skin and the virus enters the Hosts blood stream. Initial replication occurs at the site of infection which initiates the immune response of the immune system causing the activation of memory T-cell response during pre-exposure. It then stimulates the release of CYTOKINES that causes symptoms such as high fever, body weakness, headache, dizziness. Cytokines destroy cell membrane and cell wall. A virusanti body complex is produced when platelet provide a shield for the virus from exposure and binding with preexisting antibody, which causes the macrophages or monocytes to engulf the virus that has the platelet. Plasma leakage occurs and cytolysis happens. A cellular direct destruction and infection of Red bone marrow as well as immunological shortened platelet survival causing platelet lyses. Virus ultimately targets liver and spleen cells where infection produces apoptosis or cell death. This causes thrombocytopenia which leads to diagnosis of Dengue Fever.

IX. DISCHARGE PLAN M edication

Intake of appropriate vitamin supplement and diuretics to increase protection mechanism of the immune system and decreases renal vascular resistance and may increase renal blood flow, respectively. E conomic The use of nonpharmacotherapy such as drinking plenty of water will promote increase plasma in blood to increase immunity and proper hygiene and promotion of cleanliness at home and work area.

T reatment Management of such condition would be through hydration and doing control measures to eliminate vector by promoting cleanliness in the environment through proper disposal of rubber tires, changing of water of lower vases once a week, destruction of breeding places of mosquito and residual spraying with insecticides. H ygiene Advise to follow proper body hygiene and to maintain cleanliness on surroundings. This would prevent additional cases of DHF.

O ut Patient/ Follow-up Any odd signs such as fever, petechiae, recurrence of fever,etc. must be immediately reported to the physician. D iet Instruct to eat foods that are low fat, low fiber, non-irritating and non-carbonated.

Evaluation The patient in this study had undergone supportive and symptomatic management. She was admitted last July 4.

Proper nursing care such as water therapy and administration of prescribed drugs were done to promote comfort and repression of symptoms. Hygiene was also strictly implemented to avoid risk for further infection. Nursing assistance was also given to help him in his activities of daily living. Health teaching is a very important role on the part of the nurses. This is of great significance to the knowledge deficit of patients regarding health and illness. Strict compliance to the medical treatment, health teachings and medical check-up is advised. With proper nutrition and conformity to the medications & therapy, recovery would be easier and faster.