INTRODUCTION Dengue Fever is caused by one of the four closely related, but antigenically distinct, virus serotypes Dengue

type 1, Dengue type 2, Dengue type 3, and Dengue type 4 of the genus Flavivirus and Chikungunya virus. Infection with one of these serotype provides immunity to only that serotype of life, to a person living in a Dengue-endemic area can have more than one Dengue infection during their lifetime. Dengue fever through the four different Dengue serotypes are maintained in the cycle which involves humans and Aedes aegypti or Aedes albopictus mosquito through the transmission of the viruses to humans by the bite of an infected mosquito. The mosquito becomes infected with the Dengue virus when it bites a person who has Dengue and after a week it can transmit the virus while biting a healthy person. Dengue cannot be transmitted or directly spread from person to person. Aedes aegypti is the most common aedes specie which is a domestic, day-biting mosquito that prefers to feed on humans. DENGUE PREVENTION: There is no vaccine to prevent dengue. Prevention centers on avoiding mosquito bites when traveling to areas where dengue occurs and when in U.S. areas, especially along the TexasMexico border, where dengue might occur. Eliminating mosquito breeding sites in these areas is another key prevention measure. Avoid mosquito bites when traveling in tropical areas: Use mosquito repellents on skin and clothing. When outdoors during times that mosquitoes are biting, wear long-sleeved shirts and long pants tucked into socks. Avoid heavily populated residential areas. When indoors, stay in air-conditioned or screened areas. Use bednets if sleeping areas are not screened or air-conditioned. If you have symptoms of dengue, report your travel history to your doctor. Eliminate mosquito breeding sites in areas where dengue might occur: Eliminate mosquito breeding sites around homes. Discard items that can collect rain or run-off water, especially old tires. Regularly change the water in outdoor bird baths and pet and animal water containers.

PATIENTS PROFILE NAME AGE GENDER ADDRESS DATE OF BIRTH PLACE OF BIRTH NATIONALITY CIVIL STATUS RELIGION CHIEF COMPLAINT FINAL DIAGNOSIS : : : : : : : : : : : Aldy Tojino 8 y/o Male 022 Libertad St. Centro, Solana July 01, 2005 Manila City Filipino Single Roman Catholic Fever Dengue Fever Dr. Mariano/Dr.Puspitasari/ Dr.Zosa/Dr.Katalbas DATE ADMITTED TIME ADMITTED : : July 24, 2013 7:10 PM Jose R. Reyes Memorial Medical Center Pediatric Ward

ATTENDING PHYSICIAN :

ADMITTING INSTITUTION:

NURSING HISTORY Present Health History: Five days prior to admission the patient has fever and loss of appetite. According to the mother 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 fourth 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 to Saint Paul Hospital on July 24, 2013. Past Health History: According to the mother of the patient the patient did not yet experienced having serious health problems other than fever, colds and cough. He had no previous hospitalization. Family Health History: According to the mother of the patient, their family has the history of Hypertension.

PHYSICAL ASSESSMENT General assessment: conscious and coherent Initial vital signs: T=37.2 C, RR=23, BP=90/60, PR=85 Area Assessed Skin Color Soles and palms Moisture Temperature Texture Turgor Skin appendages a. Nails Nail beds Nail base Capillary refill b. Hair Distribution Color Texture Eyes Eyes Visual Acuity Technique Inspection Inspection Inspection/ Palpation Palpation Palpation Palpation 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 Transparent, smooth and convex Pinkish Firm White color of nail bed under pressure should return to pink within 2-3 seconds Evenly distributed Black Smooth 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 Same color as the skin Actual Findings Light brown skin Lighter colored palms, soles Skin normally dry Normally warm Smooth and soft Skin snaps back immediately Transparent, smooth and convex Pale Firm Returns within 2-3 seconds Evaluation Normal Normal Normal Normal Normal Normal

Inspection Inspection Inspection Inspection/ Palpation Inspection Inspection Inspection/ Palpation Inspection Inspection (penlight) Inspection

Normal Due to decreased blood flow Normal Normal

Evenly distributed Black Smooth 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 Same color as the skin

Normal Normal Normal Normal Normal

Eyebrows

Normal

Eyelashes Eyelids

Inspection Inspection

Normal Normal

Blinks involuntarily Blinks involuntarily and bilaterally up to and bilaterally up to Normal 20 times per minute 18 times per minute

Conjunctiva Sclera Cornea Pupils Iris Ears Ear canal opening

Inspection Inspection Inspection Inspection Inspection Inspection

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

Normal Normal

Hearing Acuity Nose Shape, size and skin color Nares

Inspection

Inspection

Normal

Inspection

Normal

Mouth and Pharynx Lips Buccal mucosa Gums Tongue

Inspection Inspection Inspection Inspection

Teeth Hard and soft palate Neck Symmetry of neck muscles, alignment of trachea

Inspection Inspection

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

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

Lack of fluid intake Normal Normal Normal Normal Normal

Inspection

Normal

Neck ROM Thyroid gland Thorax and Lungs Abdomen

Inspection Palpation Auscultation Inspection

Neck moves freely, without discomfort Rises freely with swallowing Clear breath sounds Skin same color with the rest of the body Clicks or gurling sounds occur irregularly and range from 5-35 per minute

Neck moves freely, without discomfort Rises freely with swallowing Clear breath sounds Skin same color with the rest of the body Clicks or gurling sounds occur irregularly and range from 20 per minute

Normal Normal Normal Normal

Bowel sounds

Auscultation

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 No lesions Moves freely without discomfort Evenly distributed Warm to touch No lesions Able to move but with assistance Normal Normal Normal Due to body weakness

Hair distribution Skin Temperature Presence of lesion ROM Neurology system Level of consciousness

Inspection Palpation Inspection Inspection

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

Behavior and appearance

Inspection

LABORATORY EXAMINATIONS HEMATOLOGY REPORT Date: July 22, 2013 PARAMETER White Blood Cells NORMAL FINDINGS 4.8-10.8 x 10^g/L ACTUAL FINDINGS 3.6 x 10^g/L ANALYSIS Decreased due to inadequate inflammatory defenses to suppress infection and humoral immunity takes place Decreased due to poor oxygen supply Decreased due to poor oxygen supply Normal Decreased

Hemoglobin Hematocrit Lymphocytes Platelet Count

M: 140-175 g/L 0.415-0.504 0.38-0.48 150-400 x 10^g/L

133 g/L 0.36 0.43 78 x 10^g/L

ABO/ Rh Type: O Rh positive

REVIEW OF 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) Leukocytes (WBC): Neutrophil Spherical cell, nucleus with two or more lobes connected by thin filaments, cytoplasmic granules stain a light pink or reddish purple, 12-15 micrometers in diameter Spherical cell, nucleus, with two indistinct lobes, cytoplasmic granules stain blue-purple, 10-12 micrometers in diameter Phagocytizes microorganism Description Biconcave disk, no nucleus, 78 micrometers in diameter Function Transport oxygen and carbon dioxide

Basophil

Releases histamine, which promotes inflammation, and heparin which prevents clot formation

Eosinophil

Spherical cell, nucleus often Releases chemical that reduce bilobed, cytoplasmic granules inflammation, attacks certain satin orange-red or bright red, worm parasites 10-12 micrometers in diameter Spherical cell with round nucleus, cytoplasm forms a thin ring around the nucleus, 6-8 micrometers in diameter Produces antibodies and other chemicals responsible for destroying microorganisms, responsible for allergic reactions, graft rejection, tumor control, and regulation

Lymphocyte

of the immune system Monocyte Spherical or irregular cell, nucleus round or kidney or horse-shoe shaped, contain more cytoplasm than lymphocyte, 10-15 micrometers in diameter Cell fragments surrounded by a cell membrane and containing granules, 2-5 micrometers in diameter 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 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 a 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 throughout 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 from forming. CLOT RETRACTION AND DISSOLUTION After a clot has formed, it begins to condense into a denser compact structure by a process known as clot retraction. Serum, which is plasma without its clotting factors, is squeezed out of the clot during clot retraction. Consolidation of the clot pulls the edges of the damaged vessels together, helping the stop of the flow of blood, reducing the probability of infection and enhancing healing. The damaged vessel is repaired by the movement of fibroblasts into damaged 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 blood clotting

Platelet

area and the formation of the new connective tissue. In addition, epithelial cells around the wound divide and fill in the torn area. The clot is dissolved by a process called fibrinolysis. An inactive plasma protein called plasminogen is converted to its active form, which is called plasmin. Thrombin and other clotting factors activated during clot formation, or tissue plasminogen activator released from surrounding tissues, stimulate the conversion of plasminogen to plasmin. Over a period of a few days the plasmin slowly breaks down the fibrin.

DRUG STUDY PARACETAMOL Dosage: 250 mg/5ml q 4 RTC Classification: Nonopioid Analgesics & Antipyretics Indication: Mild pain or fever Action: Produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulating center. Adverse Reactions: Hematologic: Hemolytic Anemia, Neutropenia, Leukopenia, Pancytopenia Hepatic: Jaundice Metabolic: Hypoglycemia Skin: Rash, Urticaria Contraindications: Contraindicated in patients hypersensitive to drug. Use cautiously in patients with long-term alcohol use because therapeutics doses cause hepatotoxicity in these patients. Nx Considerations: ALERT: Many OTC and prescription products contain acetaminophen; be aware of this when calculating total daily dose. Use liquid form for children and patients who have difficulty in swallowing. In children, dont exceed five doses in 24 hours. Patient Teaching: Tell parents to consult prescriber before giving drug to children younger than age 2. Advise patient or parents that drug is only for short-term use; urge them to consult prescriber if giving to children for longer than 5 days or adults for longer than 10 days. ALERT: Advise patient or caregiver that many OTC products contain acetaminophen, which should be counted when calculating total daily dose. Tell patient not to use for marked fever (temperature higher than 103.1F [39.5C]), fever persisting longer than 3 days, or recurrent fever unless directed by prescriber. ALERT: Warn patient that high doses or unsupervised long-term use can cause liver damage. Excessive alcohol use may increase the risk of liver damage. Caution longterm alcoholics to limit acetaminophen intake to 2g/day or less. Tell breast-feeding woman that acetaminophen appears in breast milk in low levels (less than 1% of dose). Drug may be used safely if therapy is short-term and doesnt exceed recommended doses. Interactions o Drug-Drug - Barbiturates, Carbamazepine, Hydantoins, Rifampin, Sulfinpyrazone: high doses or long-term use of these drugs may reduce therapeutic effects and enhance hepatotoxic effects of acetaminophen. Avoid using together. - Lamotrigine: may decrease lamotrigine level. Monitor patient for therapeutic effects. - Warfarin: may increase hypoprothrombinemic effects with long-term use with high doses of acetaminophen. Monitor INR closely. - Zidovudine: may decrease zidovudine effects. Monitor patient closely. o Drug-Herd - Watercress: may inhibit oxidative metabolism of acetaminophen. Discourage use together. o Drug-Food - Caffeine: may enhance analgesic effects of acetaminophen. Products may combine caffeine and acetaminophen for therapeutic advantage. o Drug-Lifestyle - Alcohol use: may increase risk of hepatic damage. Discourage use together.

A CASE STUDY ON DENGUE FEVER

Submitted by: Lozano, Maria Rhodora B.