HS2188

Adult Nursing 2

Subgroup: 3
Case study: 4
Presentation date: 04/02/

Group members:
1. DENG ANQI (144025P)
2. JANICE WONG YING EN
(145232U)
3. KHIN SU SU THEIN (140085J)
4. LU FUYING (145005F)
5. LUONG MINH QUAN
(140069P)

objectives
Explain the pathophysiology of
dengue fever
Explain the mode of transmission of
dengue fever
Discuss nursing management of
dengue haemorrhagic fever
Educate Mr. Salim how to prevent
spread of dengue fever

Case scenario
Patients name: Mr. Salim
Age: 40 years old
Diagnosis: Dengue fever
Past medical history: He has no significant medical history
Chief compliant: pain at his knees.
Medication: Ibuprofen for pain
Social History: Mr Salim stays in a 4-room HDB flat with his
elderly parents, his wife and 2 young children. His mother
keeps small potted plants outside their house, along the
corridor.

Breaking news
47-year-old Singaporean man dies from
dengue, first death reported in 2016.

(The Straits Time,

Singapores weekly Dengue Cases

National Environment Agency (201

Dengue Fever
Dengue fever is a mosquito-borne infection found
in tropical and sub-tropical regions around the
world.
It is caused by dengue virus.
The disease usually is self-limiting but in some
people can present with life-threatening
complications such as Dengue Haemorrhagic
Fever and Dengue Shock Syndrome.
There is no vaccine to protect against dengue.
At present, the only method to control or prevent
the transmission of dengue virus is to fight against
infected mosquitoes.
There are four serotypes of the virus that cause
dengue (DEN-1, DEN-2, DEN-3 and DEN-4), which
are classified as Flaviviridae.
(MOH,
2015)

Mode of transmission of Dengue Fever

Female
mosquit
o

Health Connect (2015

Pathophysiology
Thrombocytope
nia
DF without
haemorrhage
<
100,000/mm3
High Fever
(>40oC)
Headache,
Retro orbital
pain
Petechial
rashes,
thrombocytope
nia
Joint and muscle
pain
(Arthrakgia &
Myalgia)
Nausea and
vomiting
Diarrhoea

DF with
haemorrhage

Signs and
symptoms of DF

SHOC
K

Haemorrhagic
tendency or
spontaneous bleeding
Marked
thrombocytopenia
( <100,000/mm3)
Capillary
permeability
(Pleural effusion,
ascites,
hemoconcentration)

DEAT
H

Pathophysiology
Infected
mosquito feeds
on a person
Monocytes and
Macrophages ingest and
destroy pathogens
These WBCs are
targeted and
infected by the virus

It injected the
dengue virus into the
bloodstream

Infection of skin
dendritic cells

The dendritic cells travel to the lymph node

&
Alert Immune system to trigger the
immune response
The dengue virus tricks the
immune system and infect
more cells
The dengue virus
spreads throughout
the body

Spleen &
Liver
Dengue virus
affects liver
cells
Elevations of
serum
aminotransferase

Nature Education (2014

Lymph
nodes &
Bone
marrow
Suppression
of
haematopoe

Leukopenia &
Thrombocytope
nia

Pathophysiology
The infected cells (macrophages
and produce and release small
protein called interferons
Interfere with
Help the immune system
viral
recognize denguereplication
infected cells

Interfer
ons
Activate both the innate
and adaptive immune
system defenses.

Help protect uninfected

cells

Feve
r

Nature Education (2014

Pathophysiology
Adaptive
immune
response

Innate immune
response

IgG &
IgM

Recognize and
neutralize the dengue
viral particles

Cytotoxic T
cells

Recognize and kill the

cells that are infected with
dengue virus

Complement
system

Antibodies and WBCs

remove the virus

The patient
recovers from
dengue fever

Nature Education (2014

Dengue Haemorrhagic Fever

There are 4 major clinical features :
1. High fever or recent history of fever lasting
2-7 days
2. Thrombocytopenia (platelets count of <
100,000/mm3)
3. Bleeding manifestation ( petechie,
ecchymosis, gum bleeding, epistaxis)
4. Evidences of increased capillary
permeability ( haematocrit, pleural
effusion, hypoalbuminaemia)

World Health Organization (201

Nursing management

FEVE
R

Nursing Intervention

Rationale

-Monitor vital signs every

1 hour during febrile
phase.
-Monitor vital signs every
2 to 4 hour during critical
phase.
Provide tepid sponge
bath.
- Luke warm water only.
- Make sure that armpits
and groins were included
in doing TSB.
Remove excessive

Vital signs provide more

accurate indication of
core temperature.

Tepid sponge bath

helps in lowering the
body temperature.

This method
helps to
(Nursing the Nurses, 2011)

FEV
ER

Nursing management

Nursing Intervention
Promote a well-ventilated
area to patient.
Advise patient to increase
oral fluid intake.

Promote bed rest.

Administer antipyretic
medications as indicated.
<8 tablets per day

Rationale
To promote clear flow of air
in the patients surrounding
area.
Additional fluids help to
maintain hydration and
prevent elevated
temperature associated
with dehydration.
Reduce metabolic demands/
oxygen consumption (Hb)
These drugs inhibit the
prostaglandin that serve as
mediators of pain and fever.

(Nursing the Nurses, 201

Nursing management
Nursing
interventions
Platelets count and
coagulation studies
(PT,PTT) should be
monitored closely.
Pt normal range is 10-12
seconds
Ptt normal range is 30-45
seconds
Encourage patient gargle
with 10 mls of
Chlorhexidine 0.2%
mouthwash twice a day
instead of brushing teeth.

Thrombocyto
penia
Rationale

To prevent bleeding that

may lead to dehydration
and hypovolemic shock.

To prevent bleeding gums

Singhi et al. (2007

Nursing management
Nursing
interventions
Ensure patient gets
plenty of rest and
encourage bed rest
When platelet count
<20000 mm3
Invasive procedures
should be minimized as
possible
Platelets transfusion
should be done when
platelets count is less than
10,000 mm3

Thrombocyto
penia
Rationale

To prevent injury lead to

excessive bleeding

To reduce the risk of

bleeding.
To prevent risk of
excessive bleeding

Singhi et al. (2007

Nursing management

PAIN

Nursing Intervention

Rationale

Perform a comprehensive
assessment of pain which
includes location,
characteristics, onset,
duration, intensity or
severity of pain.
Reduce factors that
increase clients pain
experience (e.g., fear,
fatigue)

Pain is a subjective
experience and must be
described by the client in
order to plan effective
treatment.
Personal factors that
influence pain and pain
tolerance.
Factors that may be
precipitating pain should
be reduced to enhance
the overall pain
management program.

NursingTools (2012

Nursing management
Nursing Intervention
Educate patient about the
use of nonpharmacologic
techniques ( relaxation,
music therapy, distraction)
before, after and if possible
during painful activities.
Determine analgesic
selections (narcotic,
nonnarcotic, or NSAID)
based on type and severity
of pain .

PAIN

Rationale
Use of noninvasive pain
relief measures can
increase the release of
endorphins and enhance
the therapeutic effects
of pain relief medications.
Various types of pain
require different analgesic
approaches.

NursingTools (2012

Nursing management
Nursing Intervention
Institute safety
precautions as
appropriate if client
receives narcotic
analgesics.
Evaluate the
effectiveness of
analgesic at regular,
frequent intervals after
each administration, also
observing for any signs and
symptoms of untoward
effects (e.g., respiratory
depression, nausea and

PAIN

Rationale
Side effects of opioid
narcotics include
drowsiness and
sedation.

The analgesic dose may

not be adequate to raise
the clients pain threshold
or may be causing
intolerable or
dangerous side
effects or both. Ongoing
evaluation will assist in
NursingTools (2012
making necessary

 Capillary
Nursing management
Permeability
Ascites and pleural
effusion
Nursing
Rationale
interventions
Hematocrit level must be
checked every day until
the patient is stable.
Normal range of
hematocrit 40.7%-50.5%
Monitor Mr Salims
hydration status and
urine output closely

Provide adequate
nutrition: soft and

Hematocrit increase 20%

more
Hemoconcentration
Dehydration
Hypovolemic shock
To prevent hypovolemic
shock.
A good urine flow indicates
sufficient circulating
volume.
To prevent dehydration.

Singhi et al. (2007

Nursing management
Nursing
interventions

Capillary
Permeability
Rationale

Intravenous should be
given when platelet count
< 100,000mm3.

Rapid replace of fluid and

electrolytes Prevent
hypovolemic shock and
altered mental status.
When Hct is back to nearly If more fluid is given
normal range Stop
can cause hypervolemia,
intravenous therapy.
pulmonary edema or heart
failure.

Singhi et al. (2007

How to prevent the spread of Dengue Fever?

To prevent the spread of Dengue Fever Prevent

the breeding of its vector, the Adedes mosquito.

Do the 10-minutes 5-step

Mozzie Wipeout

National Environment Agency (201

How to prevent the spread of Dengue Fever

National Environment Agency (201

National Environment Agency (201

How to prevent the spread of Dengue Fever

National Environment Agency (201

Nursing management outside home

In a Nutshell
- Dengue is an infectious disease caused by
Flaviviridae virus.
- There are 4 serotypes of dengue (DEN-1, DEN-2,
DEN-3 and DEN-4).
- Incubation period is 3 to 14 days (average 7 days).
- Clinical manifestations include fever, headache,
petechie, together with leukopenia,
thrombocytopenia and elevated Hct.
- Administer antipyretic and fluid therapy are the
most important aspects of nursing management.
- Most patient with dengue fever recover within 2
weeks.

References:
Centers for Disease Control and Prevention (2009). Dengue and Dengue Hemorrhagic Fever
Information for Health Care Practitioners. Retrieved from
[Link]
0Practitioners_2009.pdf
Encyclopdia Britannica, Inc. (2015). Interferon. Retrieved from
[Link]
Health Connect (2015). Mode of transmission of Dengue Virus. Retrieved from
[Link]
Kwan-Gett, T. S., Kemp, C. & Kovarik, C. (2006). Infectious and Tropical Diseases, A Handbook for
Primary Care. Elsevier: Mosby.
Nature Education (2014). Host response to the Dengue Virus. Retrieved from http://
[Link]/scitable/topicpage/host-response-to-the-dengue-virus-22402106
National Environment Agency (2015). Prevent Aedes Mosquito Breeding. Retrieved from
[Link]
National Environment Agency (2015). Latest Dengue Data. Retrieved from http://
[Link]/[Link]?id=73
Richard, L. K. (2010). Diagnostic Pathology of Infectious Disease. Saunders: Elsevier.
Singhi, S., Kisssoon, N. & Bansal, A. (2007). Dengue and dengue hemorrhagic fever:
management issues in an intensive care unit. Journal de Pediatria, 83(2): S22-35.
World Health Organization (2015). Dengue and severe dengue. Retrieved from
[Link]
Nursing the Nurses (2011). Nursing care plan for Fever ( Hyperthermia). Retrieved from
[Link]
The Straits Time (2016). Retrieved from
[Link]
rst-death-reported-in-2016

Reference
The Straits Time (2016). Retrieved
from
[Link]
e/health/47-year-old-singaporean-man
-dies-from-dengue-first-death-report
ed-in-2016
National Environment Agency (2015).
Latest Dengue Data. Retrieved from
[Link]
p?id=73