Dengue Hemorrhagic Fever

Definition
Dengue hemorrhagic fever (DHF)
A syndrome due to the dengue virus that tends to affect children under 10, causing abdominal
pain, hemorrhage (bleeding) and circulatory collapse (shock). DHF starts abruptly with high
continuous fever and headache plus respiratory and intestinal symptoms with sore throat,
cough, nausea, vomiting and abdominal pain. The mortality is appreciable ranging from 6 to
30%. Most deaths occur in children. Infants under a year of age are especially at risk of death.
DHF is also called Philippine, Thai, or Southeast Asian hemorrhagic fever and dengue shock
syndrome.

Etiology
The causative agent of dengue hemorrhagic fever (DHF) is dengue virus. Aedes aegypti is
the main mosquito vector that transmits the dengue virus from person to person.When a person
is infected with dengue virus for the first time, clinical signs and symptoms are usually mild.
However, if he/she is reinfected with a different type of dengue virus, severe conditions such as
bleeding or shock will occur and can be fatal.

Pathophysiology
DHF Transmitted by bites from mosquitoes (Aedes aegypti and Aedes albopictus)
● Initial phase. The initial phase of DHF is similar to that of dengue fever and other febrile
viral illnesses. The virus is deposited in the skin by the vector, within a few days viremia
occurs, lasting until the 5th day for the symptoms to show.
● Hemorrhagic symptoms. Shortly after the fever breaks or sometimes within 24 hours
before, signs of plasma leakage appear along with the development of hemorrhagic
symptoms.
● Vascular leakage. Vascular leakage in these patients results in hemoconcentration and
serous effusions and can lead to circulatory collapse.
● Progression. If left untreated, DHF most likely progresses to dengue shock syndrome.
CLINICAL MANIFESTATION

Mild dengue fever

Symptoms can appear up to 7 days after being bitten by the mosquito that carries the virus.

They include:

● aching muscles and joints

● body rash that can disappear and then reappear
● high fever
● intense headache
● pain behind the eyes
● vomiting and feeling nauseous

Symptoms usually disappear after a week, and mild dengue rarely involves serious or fatal complications.

Dengue hemorrhagic fever

At first, symptoms of DHF may be mild, but they gradually worsen within a few days. As well as mild
dengue symptoms, there may be signs of internal bleeding.

A person with Dengue hemorrhagic fever may experience:

 ● bleeding from the mouth, gums, or nose
● clammy skin
● damage to lymph and blood vessels
● internal bleeding, which can lead to black vomit and feces, or stools
● a lower number of platelets in the blood
● sensitive stomach
● small blood spots under the skin
● weak pulse

Without prompt treatment, DHF can be fatal.

Dengue shock syndrome

DSS is a severe form of dengue. It can be fatal.

Apart from symptoms of mild dengue fever, the person may experience:

● intense stomach pain

● disorientation
● sudden hypotension, or a fast drop in blood pressure
● heavy bleeding
● regular vomiting
● blood vessels leaking fluid

Without treatment, this can result in death.

PREVENTION

Anyone who lives in or travels to an at-risk area can use a number of ways to avoid being bitten.

Share on PinterestIf you are spending time in a tropical region, use mosquito nets that are treated with
insecticide.

Clothing: Reduce the amount of skin exposed by wearing long pants, long-sleeved shirts, and socks,
tucking pant legs into shoes or socks, and wearing a hat.

Mosquito repellents: Use a repellent with at least 10 percent concentration of diethyltoluamide (DEET),
or a higher concentration for longer lengths of exposure. Avoid using DEET on young children.
Mosquito traps and nets: Nets treated with insecticide are more effective, otherwise the mosquito can
bite through the net if the person is standing next to it. The insecticide will kill mosquitoes and other
insects, and it will repel insects from entering the room.

Door and window screens: Structural barriers, such as screens or netting, can keep mosquitos out.

Avoid scents: Heavily scented soaps and perfumes may attract mosquitos.

Camping gear: Treat clothes, shoes, and camping gear with permethrin, or purchase clothes that have
been pretreated.

Timing: Try to avoid being outside at dawn, dusk, and early evening.

Stagnant water: The Aedes mosquito breeds in clean, stagnant water. Checking for and removing
stagnant water can help reduce the risk.

To reduce the risk of mosquitoes breeding in stagnant water:

● turn buckets and watering cans over and store them under shelter so that water cannot accumulate
● remove excess water from plant pot plates
● scrub containers to remove mosquito eggs
● loosen soil from potted plants, to prevent puddles forming on the surface
● make sure scupper drains are not blocked and do not place potted plants and other objects over
them
● use non-perforated gully traps, install anti-mosquito valves, and cover any traps that are rarely
used
● do not place receptacles under an air-conditioning unit
● change the water in flower vases every second day and scrub and rinse the inside of the vase
● prevent leaves from blocking anything that may result in the accumulation of puddles or stagnant
water

When camping or picnicking, choose an area that is away from still water.

Complication & Treatment

Complications from severe or acute dengue hemorrhagic fever may include:
● seizures
● brain damage
● blood clots
● damage to the liver and lungs
● heart damage
 ● shock
● death
Prompt treatment can help prevent complications, but there are no antiviral drugs for dengue
virus infection.
Treatment for dengue hemorrhagic fever
The goal of treatment is to manage symptoms and keep the infection from becoming more
severe. Severe cases may need emergency treatments such as:
● over-the-counter or prescription drugs to manage pain
● electrolyte therapy
● blood transfusions
● careful monitoring of blood pressure
● oxygen therapy
● skilled nursing observation
You may receive hydration through an IV. However, in the case of severe dengue, too
much IV fluid can lead to “third spacing,” where the fluids leak out of blood vessels. All of these
methods are aimed at controlling and alleviating your symptoms while helping your body heal
naturally. Doctors will continue to monitor your body’s response. Severe dengue fever is often
more difficult to treat because the symptoms are worse and appear at a faster rate.

Assessment and Diagnostic Findings of DHF

1. CBC
- Platelet <100,000/mm3
- Increase Ht level: indicating plasma leakage
- Reduction of neutrophils: near the end of febrile phase of illness
- Reduction of α-antiplasmin
- Hyponatremia, hypoproteinemia, and elevated level of serum aspartate aminotransferase
2. Occult blood test: positive
3. Partial thromboplastin time & prothrombin time: prolonged.
4. X-ray: pleural effusion (mostly on the right side).
5. Dengue virus isolation: isolation of the dengue virus from serum, plasma, leukocytes, or
autopsy samples
6. Immunoglobulin titers: IgM &IgG antibody titers increase to four-fold or greater
7. Immunohistochemistry: the presence of dengue virus antigen in autopsy tissue
8. Polymerase chain reaction: the presence of dengue viral genomic sequences in autopsy
tissue, serum, or CSF
9. Guaiac test: blood in feces
Nursing Management
NURSING ASSESSMENT
● Evaluation of the patient’s heart rate, temperature, and blood pressure.
● Evaluation of capillary refill, skin color and pulse pressure.
● Assessment of evidence of bleeding in the skin and other sites.
● Assessment of increased capillary permeability.
● Measurement and assessment of the urine output.
NURSING DIAGNOSIS
● Risk for bleeding related to possible impaired liver function.
● Deficient fluid volume related to vascular leakage.
● Pain related to abdominal pain and severe headaches.
● Risk for ineffective tissue perfusion related to failure of the circulatory system.
● Risk for shock related to dysfunction in the circulatory system.

PLANNING AND GOALS

● Be free of signs of bleeding.
● Display laboratory results within normal range for individuals.
● Maintain fluid volume at a functional level.
● Report pain is relieved or controlled.
● Follow prescribed pharmacologic regimen.
● Demonstrate adequate tissue perfusion.
● Display hemodynamic stability.
● Be afebrile and free from other signs of infection.

NURSING INTERVENTIONS
● Blood pressure monitoring. Measure blood pressure as indicated.
● Monitoring pain. Note client report of pain in specific areas, whether pain is increasing,
diffused, or localized.
● Vascular access. Maintain patency of vascular access for fluid administration or blood
replacement as indicated.
● Medication regimen. There must be a periodic review of the medication regimen of the
client to identify medications that might exacerbate bleeding problems.
● Fluid replacement. Establish 24-hour fluid replacement needs.
● Managing nose bleeds. Elevate position of the patient and apply ice bag to the bridge of
the nose and to the forehead.
● Trendelenburg position. Place the patient in Trendelenburg position to restore blood
volume to the head.

EVALUATION
● Absence of signs of bleeding.
● Displayed laboratory results within normal range for individuals.
● Maintained fluid volume at a functional level.
● Reported pain is relieved or controlled.
● Followed prescribed pharmacologic regimen.
● Demonstrated adequate tissue perfusion.
 ● Displayed hemodynamic stability.
● Afebrile and free from other signs of infection.

DOCUMENTATION GUIDELINES
● Factors that potentiate blood loss.
● Baseline vital signs, mentation, urine output, and subsequent assessments.
● Results of laboratory and diagnostic studies.
● Degree of deficit and current sources of fluid intake.
● I&O and fluid balance.
● Client’s description of response to pain and acceptable level of pain.
● Plan of care.
● Teaching plan.
● Response to interventions, teachings, and actions performed.
● Attainment or progress towards desired outcomes.
● Modifications to plan of care.

Reference

MedicineNet, medterms medical dictionary a-z list by Medical Editor name Melissa Conrad
Stoppler, MD.

https://www.thaitravelclinic.com/Knowledge/dengue-hemorrhagic-fever.html

https://nurseslabs.com/dengue-hemorrhagic-fever/#pathophysiology

https://d3i71xaburhd42.cloudfront.net/89f667226edacd0f0fb218744530a29f75e6083f/2-Fig
ure1-1.png

https://www.medicalnewstoday.com/articles/chills-with-fever
https://www.who.int/csr/resources/publications/dengue/012-23.pdf

https://www.healthline.com/health/dengue-hemorrhagic-fever#treatment

https://www.who.int/csr/resources/publications/dengue/012-23.pdf

https://nurseslabs.com/dengue-hemorrhagic-fever/

https://nurseslabs.com/dengue-hemorrhagic-fever/#nursing_management