PRACTICAL ASSESSMENT

CLINICAL CASE STUDY

DENGUE FEVER
Prepared by:
GROUP MEMBERS:
1. LIEW SZEE TIN (SD01-201809-003004)
2. IRDINA AQILA BINTI MOHAMMAD FAHMIN
(SD01-201809-003049)
3. NOR ALIA NATASHA BIBI BINTI NOR AZHAR
(SD01-201809-003000)
4. IBRAHIM MUSA BIN YUSOH (SD01-201809-
003023)
INTRODUCTION
 REASONS TOPIC CHOSEN

• The reason why we choose dengue fever because

it is a very common cases in Malaysia and it also
can be vital if it can’t be detected early.

• Dengue fever at the first stage is the same as any

other normal fever. So most of the time people
take it lightly and they will just take their own
medication without any description from a
qualified doctor.
 REASONS TOPIC CHOSEN (con’t)

• There’s 32,435 dengue cases recorded in 2018

on Kuala Lumpur and 53 death cases reported.
• Hereby we mustn't overlook this cases.
 60000

Statistics Of
Dengue Fever 50000
In 2017, 2018

40000

30000

20000

10000

Based on Military Health Of 0

2017 2018
Malaysia Dengue Report Death Week Reported
 DEFINITION OF DENGUE FEVER

 Dengue fever is an acute mosquito-borne viral

illness of sudden on set that usually follows a
benign course with headache, fever,
prostration, severe joint and muscle pain,
swollen glands (lymph) and rashes.

 Victim of the dengue fever will always have

contortions due intense joint and muscle pain.
 ANATOMY AND PHYSIOLOGY
The Immune system
 Dengue viral
infections can result in
a range of symptoms.
Some people show no
symptoms or just have
mild signs of the
disease, but others
develop severe
complications.
ANATOMY AND PHYSIOLOGY (con’t)

 The immune system is a second line of defense

is housed within the body: a finely tuned
immune system that recognizes and destroys
foreign substances and organisms that enter the
body.

 The immune system can distinguish between the

body's own tissues and outside substances called
antigens.
ANATOMY AND PHYSIOLOGY (con’t)
 This allows cells of the immune army to identify and
destroy only those enemy antigens. The ability to
identify an antigen also permits the immune system
to "remember" antigens the body has been exposed to
in the past; so that the body can mount a better and
faster immune response the next time any of these
antigens appear.
 The immune system also includes other proteins and
chemicals that assist antibodies and T cells in their
work. Among them are chemicals that alert
phagocytes to the site of the infection.
ANATOMY AND PHYSIOLOGY (con’t)

 The complement system, a group of proteins that

normally float freely in the blood, move toward
infections, where they combine to help destroy
microorganisms and foreign particles.

 They do this by changing the surface of bacteria or

other microorganisms, causing them to die.
 PATHOPHYSIOLOGY

Pathogenesis of Dengue:
 Dengue virus after entering in the body invades
the local macrophages and multiply there.
 Viremia develops within 24 hours. During this
period, virus travels throughout the body.
 Virus infected macrophages produces a number
of signaling proteins such as interferons, which
is responsible for many symptoms such as flue
like syndrome and pain.
 PATHOPHYSIOLOGY (con’t)

 In severe case, viral load is very high and many

vital organs are affected.
 Fluid from blood vessels starts to leak out so
that the blood volume decreases resulting in
low blood pressure.
 Decrease in blood pressure causes insufficient
supply of blood and Oxygen to vital organs
such as brains.
 PATHOPHYSIOLOGY (con’t)

 Dengue also infects bone marrow, so that

bone marrow cannot produces sufficient
platelets.
 Since platelets are needed for blood clotting,
dengue infection causes blood clotting defect
and increase the risk of bleeding.
 PATHOPHYSIOLOGY (con’t)

Primary infection:
 Primary infection is characterized by fever,
break bone fever, retro-orbital pain and flue
like syndrome.
 The person who is not previously infected with
any Flavivirus is termed as primary infection.
 In primary infection ratio of Dengue specific
IgM to IgG is high.
 PATHOPHYSIOLOGY (con’t)
Secondary infection:

 Dengue infection in
host who is
immunologically
sensitized to dengue or
other flavivirus is
termed as secondary
infection.
 Secondary infection is
characterized by rise in
antibody titer. The ratio
of IgM to IgG is low.
 PATHOPHYSIOLOGY (con’t)

Clinical manifestation:

 Dengue fever is symptomatic or asymptomatic.

 Clinical disease onsets 4-6 days after infective
mosquito bite.
ASSESSMENT
 HISTORY TAKING

A. General data
 Age: 66 years old
 Gender: Male
 Date Of Admission: 12th May 2019
 Order Of Admission: Admit to medical 4A south
tower SJMC
 Attending Physician: Dr. Siva
 Admitting Diagnosis: Fever for 3 days
 HISTORY TAKING (con’t)

B. Chief Complaint
 Intermittent fever for 3 days
 Mild headache and body ache for 3 days
 Complaining of low back pain and joint pain
 Feeling nauseous and vomited 3 times

C. Past Medical History

 Diabetes Mellitus
 Sinusitis
 HISTORY TAKING (con’t)

D. Past Surgical History

 Appendectomy (1999)
 Sinus surgery (06/10/2016)

E. Psychosocial Assessment
 Normal body build, alert, well orientation, no
paleness seen, look tired, well participation and
coordination, well co-operation

F. Allergies Reaction:
 No known allergies reaction
 HISTORY TAKING (con’t)

G. Own Medication
 Metformin 1gm BD
 HISTORY TAKING (con’t)

A. Vital Signs:
 Body Temperature - 39°C
 Pulse Rate – 79 bpm
 Respiration Rate – 22 bpm
 Blood Pressure – 130/70 mmHg
 O2 Saturation – 99% (Room Air)

 Body Weight – 78.3 kg

 Height – 175 cm
 BMI – 25.6 Kg/m2 (Slightly overweight)
 NURSING OBSERVATIONS

As we notice patient’s sign and symptoms:

high fever as evidenced by body temperature

of 39 degree Celsius
pain in the joints, muscles and having low
back pain
mild frontal headache
feeling nauseous and vomited 3 times
DIAGNOSTIC
ASESSMENT &
FINDINGS
 FULL BLOOD COUNT
Blood Result Normal Range Remarks
Component
WBC 12.0 4-11 X 10^9/L Increased
Hb 9.5 11.5-18.0 g/dL Low
Platelet 40 150-450 x 10^9/L Low
Hematocrit 38 36-56 % Normal
MCV 80 79-96 fL Normal
MCH 29 27-32 pg Normal
MCHC 31.0 30.0-36.0 g/dL Normal
 FULL BLOOD COUNT (con’t)

Blood Result Normal Range Remarks

Component

RDW 17.5 10-16.5% Increased

Neutrophil 8.0 ; 2.9-7.9 x 10^9/L; Increased

(absolute; %) 19.7 87.4%

Lymphocyte 4.5 ; 1.8-4.0 x 10^9/L; Increased

(absolute; %) 72.6 26.0%
NURSING CARE
PLAN
 NURSING CARE PLAN

Nursing Diagnosis:
1. Altered body temperature related to dengue as
evidence by temperature of patient is 39°C.
Planning:
 After nursing intervention has been carried out,
the body temperature of the patient will decrease
from 39°C to a normal range of 36.4°C to 37.4°C.
 NURSING CARE PLAN (con’t)
Interventions Rationales
Remove unnecessary clothing To decrease the warm and
that could only aggravate heat. increase the evaporative for
cooling.
Promote well ventilated area to To promote clear flow of air in
patient. patient’s area and to promote
heat loss.
Encourage increase fluid intake. To promote hydration.
Provide tepid sponge bath. To reduce patient’s body
temperature
Give antipyretic medications as Aids in lowering down body
prescribed. temperature.
 NURSING CARE PLAN (con’t)

Evaluation/Nursing outcomes:
 After 1 hour of nursing interventions, the
temperature of the patient decreased from 39°C
to a normal range of 36.5°C.
 Patient’s body is well hydrated.
 NURSING CARE PLAN (con’t)

Nursing Diagnosis:
2. High Risk for Bleeding related to low platelet
count and decreased blood clotting factor.

Planning:
 Will constantly monitor patient’s condition in
order to decrease the chance of bleeding.
 NURSING CARE PLAN (con’t)
Interventions Rationales

Monitor signs of decreased Platelet decline is a sign of

platelets accompanied by blood vessel leakage, which
clinical signs. at some stage may cause
clinical signs such as
epistaxis, petechia.
Monitor platelets every day. With the platelets are
monitored on a daily basis, it
can be seen the level of
vascular leak and possible
bleeding experienced by the
patient.
 NURSING CARE PLAN (con’t)
Interventions (con’t) Rationales (con’t)
 Interventions:
Instruct patient to get a lot of Patient activity can lead to
rest (bed rest). uncontrolled bleeding.
Provide information to clients The involvement of patients
and families to report any and families may help to early
 Evaluation:
signs of bleeding such as: treatment if there is bleeding.
hematemesis, melena,
epistaxis.
Anticipation of bleeding: use a Prevent further bleeding.
soft toothbrush, maintain oral
hygiene, apply pressure take
5-10 minutes after each blood.
 NURSING CARE PLAN (con’t)

Evaluation/Nursing outcomes:
 Displayed laboratory results of platelet count
within normal range for patient.
 Patient’s pulse rate is within normal range with no
signs of tachycardia.
 There is no sign of further bleeding and patient’s
platelets increased.
 NURSING CARE PLAN (con’t)

Nursing Diagnosis:
3. Altered Fluid Volume and Electrolyte Balance related
to dehydration as evidence by i/o chart.

Planning:
 Will demonstrate to patient to practice lifestyle
changes to avoid progression of dehydration.
 Will ensure patient stays hydrated.
 NURSING CARE PLAN (con’t)
Interventions Rationales

Monitor vital signs every 3 Helps identify fluctuations

hours / more often. in intravascular fluid.

Observation of capillary Indications adequacy of

refill. peripheral circulation.

Observation of intake and Decrease in urine output

output. Note color of urine / concentrated suspected
concentration. dehydration.
 NURSING CARE PLAN (con’t)
Interventions (con’t) Rationales (con’t)
 Interventions:
Suggest patient to drink To consume body fluids
1500-2000 ml/day (as orally and to promote
tolerated). hydration.
 Evaluation:
Collaboration: intravenous It can increase the amount
fluid administration. of body fluid, to prevent
shock hypovolemic.
 NURSING CARE PLAN (con’t)

Evaluation/Nursing outcomes:
 Patient demonstrates lifestyle changes to avoid
progression of dehydration.
 Maintained fluid volume at a functional level.
 There is no sign of pre-shock.
 NURSING CARE PLAN (con’t)

Nursing Diagnosis:
4. Alteration in comfort related to low back pain.

Planning:
 Will ensure patient describes satisfactory pain
control at level less than 3 to 4 on a rating scale of
0 to 10
 NURSING CARE PLAN (con’t)
Interventions Rationales
Needs to reports of pain To decrease anxiety in the
immediately. patient.
Administer analgesics ordered To help reduce the pain from
by the physician, for example getting worse.
acetaminophen.
Suggest patient to get enough Promotes comfort and less
rest periods to promote relief , pressure of muscles during the
sleep and relaxation rest.
Provide massage to the affected Promotes relaxation of muscles
area every 4 hours. to ease pain.
Pelvic traction continuously in Relieves pressure on nerves of
proper body alignment. lumbosacral area.
 NURSING CARE PLAN (con’t)

Evaluation/Nursing outcomes:
 Patient’s condition is much better now and no
complains of pain.
 Patient describes satisfactory pain control at level
of 2.
TREATMENT/
PROCEDURE
TREATMENT OF DENGUE INFECTION

 Currently, no specific medications exist to treat

dengue virus infection or disease.
 Treatment for symptoms includes rest and the use
of acetaminophen to relieve fever and pain. Avoid
aspirin.
 Patients should also be advised to drink plenty of
fluids if diagnosed.
 If anyone has recently traveled to a known
endemic area and are displaying any of the
symptoms of dengue infection, they should consult
their physician immediately
 MEDICATION (PHARMACOLOGY)
No Medication Indication Side Effects Nursing
Responsibilitie
s

1 Esomeprazole Inj Gastroesophage  Headache Instruct

(Nexium, 40mg al reflux disease  Cough patient to
IV, BD (GERD)  Dry skin report severe
Group: Antacids,  Diarrhea headache,
Antireflux  Nausea fever, chills,
Agents  Vomit and changes in
&Antiulcerants color of urine
or stool.
 MEDICATION (con’t)
No Medication Indicatio Side Effects Nursing
Responsibiliti
n es
2 Lantus Solostar Diabetes  Hypoglycemia Tell patient to
14 IU, SUBCUT, ON  Rash take dose
Group: Insulin  Pain at once daily at
glargine injection site the same time
each day.
3 NovoRapid Inj Diabetes  Anxiety Educate
(Flexpen)  Blurred vision patient about
12 IU, SUBCUT,  Confusion diabetes and
insulin  Drowsiness how it affects
Group: Insulin the body, self-
aspart care and
necessary.
 MEDICATION (con’t)
4 Ondansetron To manage  Confusion Instruct patient
Injection (Zofran) nausea &  Dizziness to report any
4mg IV, TDS vomit  Fast symptoms of
Group: Antiemetic heartbeat an arrhythmia
 Headache while taking
 Weakness ondansetron.
5 Paracetamol To treat mild  Nausea Make sure
(Panadol) moderate  Stomach patient is aware
1000mg Orally, QID pain; fever pain and they must
Group: Analgesics (high  Loss of not exceed the
(non-opioid) & temperature) appetite recommended
Antipyretics  Dark urine dose.
 Jaundice
 DRUG ACTION

A. ESOMEPRAZOLE (NEXIUM)
 is in class of drug called proton pump inhibitor
(PPIs) which block the production of acid by
stomach.
PPIs used for the treatment of condition such as
stomach and duodenal ulcers, gastroesophageal
reflux disease (GERD) and Zollinger-Ellison
syndrome which all are caused by stomach acid.
By blocking the enzyme, the production of acid is
decreased and this allows the stomach and
esophagus to heal.
 DRUG ACTION (con’t)

B. LANTUS SOLOSTAR.
 The primary activity of insulin including insulin
glargine is regulation of glucose metabolism.
Insulin and its analogs lower blood glucose
levels by stimulating peripheral glucose uptake,
especially by skeletal muscle and fat and by
inhibiting hepatic glucose production.
Insulin inhibit lipolysis in the adipocyte,
proteolysis and enhances protein synthesis.
 DRUG ACTION (con’t)

C. NOVORAPID
 is replacement of insulin that is very similar to the
insulin made by the body but absorbed faster by the
body.
This allows it to start acting faster than human
insulin.
The replacement insulin works in the same way as
naturally produced insulin and help glucose enter cells
from the blood.
By the controlling the level of blood glucose, the
symptoms and complication of diabetes are reduced.
 DRUG ACTION (con’t)

D. ONDANSETRON (ZOFRAN).
 Block the action of serotonin 5-HT3 receptor
sites.
 Serotonin 5-HT3 receptor sites are present on
vagal nerve terminals and certain of the brain.
 Serotonin 5-HT3 antagonists bind to the 5-HT3
receptor sites to suppress vomit and nausea.
 The binding of these antagonists to 5-HT3
inhibits serotonin from eliciting its effects.
 DRUG ACTION (con’t)

A. PARACETAMOL (PANADOL)
 to relieve pain by reducing the production of
prostaglandins in the brain and spinal cord.
Prostaglandins are produced by the body in
response to injury and certain diseases.
One of their actions is to sensitize nerve endings,
so that when that area is stimulated it causes pain,
presumably to prevent us from causing further
harm to the area.
PATIENT’S DAY TO
DAY PROGRESS IN
RELATION TO
TREATMENT
 Day 1

 When patient came to ER, his vital signs were taken

and physical examination was done.
 His vital signs were all within normal limits for his
age.
 At ER, doctor inserted branula size 20G on patient’s
right hand. His blood was taken for Full Blood Count
(FBC) test to determine what caused the patient to
have fever and other symptoms.
 Iv drip NaCl 140mls/hr was ordered to commence as
patient was dehydrated.
 Day 1 (con’t)

 Patient was admitted to Medical ward 4A south

tower under Dr Siva.
 Patient’s blood test FBC result was reviewed by Dr
Siva.
 Dengue NSI, Renal Profile 2, Liver Function Test
(LFT), Chest X-Ray and Electrocardiogram (ECG)
were ordered.
 Patient is still having high fever during admission so
Dr Siva ordered IV Rocephin 2gm daily and was
given to patient..
 Day 2

 Staff Nurse M checked the patient’s vital signs and

noted that all the reading was stable but patient still
had fever at the temperature of 38.5°C.
 Patient’s Iv drip NaCl was reduced to 8 hourly as
ordered by the doctor.
 Paracetamol was served by Staff Nurse M and
Student Nurse E.
 Staff Nurse M and Student Nurse E also provided
tepid sponging to bring down patient’s temperature.
 Day 2 (con’t)

 Doctor ordered to give patient one pint packed cell

of blood transfusion as he noted that patient’s
haemoglobin level is low.
 Prophylactic platelet transfusion was also ordered
to be given to patient as patient’s platelet count in
the blood test results shown was very low.
 After the completion of blood and platelet
transfusion, patient repeated the same blood test.
 Hb and PC has increased at the normal range,
which are 12 for haemoglobin and 150 for platelet
count respectively.
 Day 3

 Patient repeated same blood test for Hb and PC

monitoring.
 The test results were normal.
 Patient’s vital signs were also stable.
 Patient slept well on room air and was afebrile.
 All limbs moving at normal power.
 No SOB noted.
 Doctor reviewed patient’s blood test result and
general condition was fine.
 Health education was given and patient was allowed
to discharge.
 HEALTH EDUCATION

The best protection from dengue fever is to

prevent bites by an infected mosquito.
Be sure to:
 Use screens on doors and windows, and
promptly repair broken or damaged screens.
Keep unscreened doors and windows shut.
 Always make sure to wear long-sleeved shirts,
long pants, shoes, and socks when going outside,
and use mosquito netting over beds at night.
 HEALTH EDUCATION (con’t)

 Always use insect repellent as directed when

doing activities outdoor or going outside of the
house. Choose one with DEET or oil of lemon
eucalyptus.

 Limit the amount of time spending outside

during the day, especially in the hours around
dawn and dusk, when the mosquitoes are most
active.
 HEALTH EDUCATION (con’t)

 Don't give mosquitoes places to breed. They lay

their eggs in water, so get rid of standing water in
things like containers and discarded tires, and be
sure to change the water in birdbaths, dog bowls,
and flower vases at least once a week.

 By taking these precautions and keeping your

kids away from areas that have a dengue fever
epidemic, the risk of contracting dengue fever is
small for international travelers.
 CONCLUSION

 Suspicion of such diseases of dengue fever should

be high whenever a travelling history is suggestive
while dealing with cases of fever in travelers.

 In the era of globalization, an increase awareness of

the health professionals about tropical and endemic
diseases would improve our ability to diagnose and
improve the outcome of different conditions and
this will save our health resources by avoiding
unnecessary investigations.
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