Dengue Case Study

Introduction Dengue is a mosquito-borne infection that in recent decades has become a major international public health concern. Dengue is found in tropical and sub-tropical regions around the world, predominantly in urban and semi-urban areas. Dengue haemorrhagic fever (DHF), a potentially lethal complication, was first recognized in the 1950s during dengue epidemics in the Philippines and Thailand. Today DHF affects most Asian countries and has become a leading cause of hospitalization and death among children in the region. There are four distinct, but closely related, viruses that cause dengue.

Recovery from infection by one provides lifelong immunity against that virus but confers only partial and transient protection against subsequent infection by the other three viruses. There is good evidence that sequential infection increases the risk of developing DHF. The incidence of dengue has grown dramatically around the world in recent decades. Some 2. 5 billion people – two fifths of the world’s population – are now at risk from dengue. WHO currently estimates there may be 50 million dengue infections worldwide every year.

The spread of dengue is attributed to expanding geographic distribution of the four dengue viruses and their mosquito vectors, the most important of which is the predominantly urban species Aedes aegypti. A rapid rise in urban mosquito populations is bringing ever greater numbers of people into contact with this vector, especially in areas that are favourable for mosquito breeding, e. g. where household water storage is common and where solid waste disposal services are inadequate. Dengue viruses are transmitted to humans through the bites of infective female Aedes mosquitoes.

Mosquitoes generally acquire the virus while feeding on the blood of an infected person. After virus incubation for eight to 10 days, an infected mosquito is capable, during probing and blood feeding, of transmitting the virus for the rest of its life. Infected female mosquitoes may also transmit the virus to their offspring by transovarial (via the eggs) transmission, but the role of this in sustaining transmission of the virus to humans has not yet been defined. Infected humans are the main carriers and multipliers of the virus, serving as a source of the virus for uninfected mosquitoes.

The virus circulates in the blood of infected humans for two to seven days, at approximately the same time that they have a fever; Aedes mosquitoes may acquire the virus when they feed on an individual during this period. Some studies have shown that monkeys in some parts of the world play a similar role in transmission. Dengue fever is a severe, flu-like illness that affects infants, young children and adults, but seldom causes death. The clinical features of dengue fever vary according to the age of the patient.

Infants and young children may have a fever with rash. Older children and adults may have either a mild fever or the classical incapacitating disease with abrupt onset and high fever, severe headache, pain behind the eyes, muscle and joint pains, and rash. Dengue haemorrhagic fever (DHF) is a potentially deadly complication that is characterized by high fever, often with enlargement of the liver, and in severe cases circulatory failure. The illness often begins with a sudden rise in temperature accompanied by facial flush and other flu-like symptoms.

The fever usually continues for two to seven days and can be as high as 41°C, possibly with convulsions and other complications. In moderate DHF cases, all signs and symptoms abate after the fever subsides. In severe cases, the patient’s condition may suddenly deteriorate after a few days of fever; the temperature drops, followed by signs of circulatory failure, and the patient may rapidly go into a critical state of shock and die within 12 to 24 hours, or quickly recover following appropriate medical treatment.

There is no specific treatment for dengue fever. For DHF, medical care by physicians and nurses experienced with the effects and progression of the complicating haemorrhagic fever can frequently save lives – decreasing mortality rates from more than 20% to less than 1%. Maintenance of the patient’s circulating fluid volume is the central feature of DHF care. At present, the only method of controlling or preventing dengue virus transmission is to combat the vector mosquitoes. Vector control is implemented using environmental management and chemical methods.

Proper solid waste disposal and improved water storage practices, including covering containers to prevent access by egg-laying female mosquitoes are among methods that are encouraged through community-based programmes. The application of appropriate insecticides to larval habitats, particularly those that are useful in households, e. g. water storage vessels, prevents mosquito breeding for several weeks but must be re-applied periodically. Small, mosquito-eating fish and copepods (tiny crustaceans) have also been used with some success.

During outbreaks, emergency vector control measures can also include broad application of insecticides as space sprays using portable or truck-mounted machines or even aircraft. However, the mosquito-killing effect is transient, variable in its effectiveness because the aerosol droplets may not penetrate indoors to microhabitats where adult mosquitoes are sequestered, and the procedure is costly and operationally difficult. Regular monitoring of the vectors’ susceptibility to widely used insecticides is necessary to ensure the appropriate choice of chemicals.

Active monitoring and surveillance of the natural mosquito population should accompany control efforts to determine programme effectiveness. Anatomy and Physiology Blood Components * Plasma is a straw-colored liquid portion of the blood in which the cells and platelets are suspened. It makes up approximately 50-55% of a blood sample. It consist of water (approximately 92%), amino acids, proteins, carbohydrates, lipids, vitamins, hormones, electrolytes and cellular wastes. Serum is essentially the same as plasma, only it has no fibrinogen and clotting factors. If whole blood is allowed to clot and the clot will be removed. Blood cells, along with platelets, comprise the remaining portion of the blood sample. The blood volume is approximately 8 percent of the total body weight. * Erythrocytes, or red blood cells (RBCs), transport oxygen (O2) and carbon dioxide (CO2) in the blood. Erythrocytes contain the protein hemoglobin to which both O2 and CO2 attach. * Mature 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 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. About 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? About 65% of the CO2 collected from tissues travels in the blood plasma as HCO3?. Because they lack cellular organelles and thus physiology to maintain them, erythrocytes survive for only about 120 days. * Leukocytes, or white blood cells (WBCs) has three types: * Granulocytes constitute 60-80% of the total number of leukocytes. They contain granules in their cytoplasm and act as phagocytes. The three types of granulocytes are neutrophils, eosinophils and basophils which are also referred as polymorphonuclear leukocytes. * Neutrophils are the most plenty of the granulocytes (55-70%). They act as a phagocytes that are less mature than a fully developed neutrophil.

A shift to the left describes the increase in immature neutrophils resulting from activation of the bone marrow to produce white blood cells in response to infectious processes. As the bands mature, the nucleus becomes segmented and develops into neutrophils, which is why neutropils are often referred to as “segs”. Neutrophils are the first type of phagocytic cell to arrive at the site of invasion, drawn by chemicals released by damaged tissue and invading organism * Eosinophils accounts for 1% to 4% of the total number of circulatory leukocytes. They are also phagocytes but they are not efficient in this role compare to the neutrophils.

They have the ability to engulf antigen-antibody complexes from allergic responses. They also have the ability to protect the individual from parasitic infections * Basophils (0. 5%-1% of all leukocytes) contain histamine, heparin and serotonin. These are similar to the mast cell activity seen in allergic and inflammatory reactions. Basophils have limited phagocytic activity. * Monocytes account for 2%-3% of circulating leukocytes and are large phagocytic cells produced in the bone marrow. Once they leave the circulation, they reside in tissues to become macrophages. Macrophages are responsible for removing dead and senescent cells as well as having the ability to engulf microorganisms. * Lymphocytes account for 20%-40% of circulating leukocytes. They originate primarily from the lymph nodes and also from the bone marrow. There are three types of lymphocytes: T-lymphocytes,B-lymphocytes and NK cells or mull cells. * Thrombocytes or platelets. Many of platelets are present in circulation. The spleen contains the remainder of platelets. Approximately 20,000 to 40,000 new platelets per cubic millimetre of blood are produced each day.

The life span of platelets is approximately 10days. * `The major functions of platelets are to maintain homeostasis and coagulation. They have the ability to plug breaks in blood vessels and therefore are able to maintain the integrity of these vesssels * Platelets also release thromboplastin (factor 111) necessary for the conversion of prothrombin to thrombin, which is the first step of coagulation. Demographic Profile Name Address Age Sex Date of Birth Place of Birth Nationality Religion Civil Status Educational Attainment Father Occupation Mother Occupation OTHER

Admitting Diagnosis: Acute Tonsilopharyngitis T/C Dengue Fever Syndrome Principal Diagnosis: Dengue Hemorrhagic Fever Attending Physician: Hospital Admitted: Date/Time Admitted: Date/Time Discharged: History of Present Illness According to the significant other, one day prior to admission the patient suffered fever with a temperature of 39. 5 Centigrade accompanied by productive cough able to expectorate yellowish non-blood tinged sputum. The patient was given Ibuprofen (Dolan) 250mg/ml to be taken every 4 hours but it didn’t relieve the patient. It was then followed up with Paracetamol 250mg/5ml with the same frequency.

Few hours prior to admission, the patient still had a persistent fever which prompts the significant other to consult the present institution and through assessment, it was then advised that the patient should be admitted for further examination and management. History of Past Illness Through interview to the significant other, the patient was said to be completely immunized. The patient hasn’t been hospitalized for the past 7 years due to any accident or illnesses. The patient was said to be living in a concrete house but with a poor environment sanitation such as presence of garbages and stagnant water.

Head to Toe Assessment BODY PART| FINDINGS| Skull| ? proportional to the size of the body, round, with prominences in the frontal area anteriorly ; the occipital area posteriorly, symmetrical in all planes, gently curved| Scalp/Hair| ? scalp is white, clean, free from masses, lumps, nits, dandruff ; lesions, with no areas of tenderness upon palpation; hair is black, evenly distributed ; covers the whole scalp, thick ; shiny| Face| ? oblong shaped, symmetrical, smooth ; no involuntary muscle movements| Eyes/Vision| ? yes are parallel ; evenly placed, symmetrical, nonprotruding, with scant amount of secretions, both eyes black ; clear; sclera is white ; clear; eyebrows are black, symmetrical, thick, can raise both symmetrically ; without difficulty, evenly distributed ; parallel with each other; eyelashes are evenly distributed ; turned outward; upper eyelids cover a small portion of the iris, cornea ; the sclera when the eyes are open, when the eyes are closed the lids meet completely, symmetrical ; the color is the same as the surrounding skin; lid margins are clear, without scaling or secretions; lower palpebral conjunctiva are shiny, moist, transparent ; salmon pink in color; iris are proportional to the size of the eye, round ; symmetrical; pupils are from pinpoint to almost the size of the iris, round, symmetrical, constricts with increasing light ; accommodation; able to move eyes in full range of directions| Ears/Hearing| ? ears are parallel, symmetrical, proportional to the size of the head, bean-shaped, helix is in line with the outer canthus of the eye, skin is the same color as the surrounding area ; clean; ear canal ispinkish, clean, with scant amount of cerumen ; a few cilia; able to hear whisper spoken 2 feet away | Nose| ? nose is in midline, symmetrical, patent; internal nares are clean, dark pink with few cilia| Mouth/Lips| ? lips are pinkish, symmetrical, lip margin is well-defined, mooth ; moist; gums are pinkish, smooth, moist, no swelling, no retraction, no discharge; no dental caries; tongue is pinkish, slightly rough on top, smooth along the lateral margins, moist, shiny ; freely movable; cheeks are pinkish, moist ; smooth; frenulum is in midline, straight ; thin; soft palate is pinkish, smooth ; moist; hard palate is slightly pinkish; uvula is at the center, symmetrical ; freely movable| Neck| ? proportional to the size of the body ; head, symmetrical ; straight, no palpable lumps, masses or areas of tenderness| Thorax and Lungs| ? chest contour is symmetrical, spine is straight, no lumps, no masses, no tender areas, with clear breath sounds| Heart| ? no abnormal pulsations, pulsations are palpable ; visible in apical area| Breast| ? symmetrical, pinkish nipples, no cracks ; discharges, uniform in skin color, smooth ; intact, no lumps, masses ; tenderness| Abdomen| ? bdominal skin is unblemished, no scars, color is uniform with the body color, abdomen is rounded with symmetric movements caused by respiration; umbilicus is concave| Upper Extremities| ? symmetrical, with visible veins, fine hair evenly distributed, warm, dry ; elastic upon palpation, with area of tenderness on the left arm; palms are pinkish, warm, soft ; elastic; nails are transparent, smooth ; convex with light pink nail beds ; white translucent tips; 5 fingers in each hand; both shoulders, arms, elbows, hands ; wrists can be moved in different range of motion with relative ease; marks of petechial rashes| Lower Extremities| ? kin is smooth, fine hair is evenly distributed, absence of varicose veins, muscles symmetrical, length symmetrical, 5 toes in each foot, sole ; dorsal surface is smooth with pink nail beds ; white translucent tips; both legs, knees, ankles, ; toes can be moved in different range of motion with relative ease| Pathophysiology Predisposing factor Tropical areas Stimulates WBC Bite from mosquito (Aedes Aegypti) Virus enters circulation (Chikungunya Virus)) Virus disseminated to blood Precipitating factor Poor environmental sanitation Mosquito carrying dengue virus Thermostat change Fever, flash skin and chills Stimulates hypothalamus Release of pyrogen IgG adheres to the platelet (initiates destruction of the platelet) Decrease clotting function thrombocytopenia Possible for bleeding rashes, melena, abdominal pain, low hgb, low hct and low rbc) stimulates intense inflammatory response Related Treatment Drug Infomation| Contraindications| Side Effects/ Adverse Effects| Nursing Intervention| Generic Name: ParacetamolDoctor’s Order: 250mg/5ml5ml p. o. every 4 hoursClassification: Anti-pyreticIndication: Treatment for feverDrug Action:Decrease fever by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilation| Contraindicated with allergy to acetaminophenUse cautiously with impaired hepatic function, chronic alcoholism, pregnancy, lactation. Side Effects Stimulation Drowsiness Abdominal painAdverse Effects CNS: Headache CV: Chest pain, dyspnea, myocardial damage when doses of 5-8g/day are ingested daily for several weeks or when doses of 4g/day are ingested for 1 year GI: Hepatic toxicity and failure, jaundice GU: Acute renal failure, renal tubular necrosis Hematologic: Methemoglobinemia- cyanosis, hemolytic anemia- hematuria, anuria, neutropenia, leukopenia, pancytopenia, thrombocytopenia and hypoglycaemia Hypersensitivity: Rash, fever| Consideration * Assess for the temperature of the patient before giving the medication and during the peak level of the drug. Avoid using multiple preparations containing acetaminophen * Discontinue drug if hypersensitivity reactions occur. * Treatment for overdose: Monitor serum levels regularly, N-acetylcysteine should be available as a specific antidote; basic life support measure may be necessary. Education * Do not exceed recommended dose; do not take for longer than 10 days. * Advise patient that drug is only for short term use and to consult the physician if giving to children for longer than 5 days or adults for longer than 10 days. * Warn patient that high doses or unsupervised long term use can cause liver damage. * Report rash, unusual bleeding or bruising, yellowing of skin or eyes, changes in voiding patterns. |

Drug Infomation| Contraindications| Side Effects/ Adverse Effects| Nursing Intervention| Generic Name: AmpicillinDoctor’s Order: Ampicillin 500mg IVClassification: PenicillinIndication: Active against: Streptococci, non penicillinase producing staphylococci, Listeria, Pneumococci, Enterococci, Haemophilus influenza, E. coli, Enterobacter, Klebsiella, Proteus mirabilis, Neisseria meningitides, N. gonorrhea, Shigella, SalmonellaDrug Action:Binds to bacterial cell wall, resulting in cell death| Contraindicated with allergy. | Side Effects: diarrhea, nausea and vomiting, rashesAdverse Effects: Seizure| Consideration * Monitor intake and output. * Assess food tolerance. Observe patient for signs and symptoms of Anaphylaxis( rash, pruritus, laryngeal edema, and wheezing) * Assess skin for “ampicillin rash”, normal allergic, dull red, macular or maculopapular, mildly pruritus. * Obtain a history before initiating therapy to determine previous use and reactions to penicillins and cephalosphorins. Education * Instruct the patient to take medication around the clock and to finish the drug completely as directed, even if feeling better. * Caution patient to notify health care professional if fever and diarrhea occur, especially if stool contains blood, pus or mucus. | Date| Shift| Bot. #| Kind of Solution| Volume| Drops| CC hr| Time Started| 8/11/2011| 2-10| 1| PLR| 1L| | | 4:40pm| 8/12/2011| 6-2| 2| PLR| 1L| | | 8:05pm| 8/12/2011| 2-10| 3| D5 0. 3 Nacl| 1L| | | 9pm| Laboratory Result Hematology

For a Complete Blood Count (CBC), specimens of venous blood are taken, it includes hemoglobin and hematocrit measurements, erythrocyte (RBC) count, leukocyte (WBC) count, red blood cell (RBC) indices, and a differential white cell count. The CBC is a basic screening test and one of the most frequently ordered blood tests. | 08/11/2011 2:54pm| 08/12/2011 10:46am| 08/13/201105:29 pm| Normal Values| WBC| 3. 6| 4. 0| 2. 3| 5. 0 – 10. 0 X 10 g/L| DIFFERENTIAL COUNT| * NEUTROPHIL| 0. 66| 0. 27| 0. 34| 0. 40 – 0. 60| * LYMPHOCYTES| 0. 23| 0. 59| 0. 60| 0. 20 – 0. 40| * MONOCYTES| 0. 10| 0. 12| 0. 03| 0. 02 – 0. 08| * EOSINOPHILS| 0. 01| 0. 01| 0. 02| 0. 1 – 0. 03| * BASOPHILS| 0. 00| 0. 01| 0. 01| 0 – 0. 02| HEMOGLOBIN | 125| 135| 131| 140 – 175 g/L| HEMATROCRIT| 0. 37| 0. 40| 0. 39| 0. 42 – 0. 48| RBC| 4. 61| 4. 96| 4. 82| 5. 5 – 6. 5 X10 12/L| MCU| 81| 81| 80| 88 – 96| MCH| 27. 2| 27. 2| 27. 2| 27 – 33 pg| MCHC| 338| 337| 338| 300 – 360 g/L| RDW| 11. 8| 11. 7| 11. 7| 12. 7 – 22. 7 %| PLATELET| 140| 142| 145| 150 – 450 X 10 g/L| MPV| 4. 74| 4. 6| 4. 6| 4. 5 – 7. 5 Fl| Urinalysis Urine tests include tests for specific gravity, pH and the presence of abnormal constituents such as glucose, ketones, protein, and occult blood. 8/11/2011 3:44 PM Urinalysis Macroscopic| | Chemical| |

Color:Transparency:Microscopic:RBC:PUS Cells:BacteriaEpithelial CellsMucus ThreadsCrystalsAmorphous UratesAmorphous PhosphatesAmorphous BiuratesCalcium oxalate CastPUS CastCoarse Granular Cast:Fine Granular Cast:Remarks| YellowClearMicroscopic0 – 2 / HPF0 – 2 / HPFFewFewFewFew| SpecificPHNitrate: Protein:Glucose:ketone:Urobilinogen:Bilirubin:Leukocytes:Blood:Yeast Cells:Pregnancy:Micral Test:Others:| 1. 0156. 5NegativeNegativeNegativeNegativeNormalNegativeNegativeNegat ive| Serology Description| Result| Dengue NS: Ag| Negative| Dengue Blot| IgG| Negative| IgM| Negative| Recommendations * Boost immune system through eating rich in vitamin C foods and nutritious well-balance diet. * Increase oral fluid intake. * Call the physician and report any untoward signs and symptoms such as bleeding. Cover water drums and water pails at all times to prevent mosquitoes from breeding. * Replace water in flower vases once a week. * Clean all water containers once a week. Scrub the sides well to remove eggs of mosquitoes sticking to the sides. * Clean gutters of leaves and debris so that rain water will not collect as breeding places of mosquitoes. * Old tires used as roof support should be punctured or cut to avoid accumulation of water. * Collect and dispose all unusable tin cans, jars, bottles and other items that can collect and hold water * Preventive Measures: (CLEAN). Accdg to DOH. Chemically treated mosquito nets Larvae eating fish Environmental clean up Anti mosquito soap/lotion Neem trees/eucalyptus tree