dengue hemorrhagic fever- case study

I. INTRODUCTION

A. OVERVIEW

Dengue is a mosquito-borne disease cause by any one of four closely related

dengue viruses (DENV -1,-2,-3 and -4). Infection with one serotype of DENV provides

immunity to that serotype for life, but provides no long-term immunity to other

serotypes. Thus, a person can be infected as many as four times, once with each

serotype.

Dengue Hemorrhagic Fever, also known as Severe Dengue, was first recognized

in the 1950s during dengue epidemics in the Philippines and Thailand. Today, severe

dengue affects most Asian and Latin American countries and has become a leading

cause of hospitalization and death among children in these regions. Typical cases of

DHF are characterized by four major clinical manifestations: high fever, hemorrhagic

phenomena, and often, hepatomegaly and circulatory failure.

Infected humans are the main carriers and multipliers of the virus, serving as as

source of the virus for uninfected mosquitoes. Patients who are already infected with the

dengue virus can transmit the infection (4-5 days, maximum 12) via Aedes mosquitoes

after their first symptoms appear.Reference: World Health Organization (WHO) 2011. Retrieved from: http://who.int.com

Page | 1

Mode of Transmission

1. Bite of an infected mosquito, principally the Aedes Aegypti.

a. Aedes aegypti is a day-biting mosquito (they appear two hours after sunrise

and two hours before sunset).

b. It breeds in an areas of stagnant water.

c. It has limited, low flying movement.

d. It has fine whole dots at the base of the wings and white bands on the legs.

2. Aedes Albopictus may contribute to the transmission of the dengue virus in rural

areas.

3. Other contributory mosquitoes:

a. Aedes polynensis

b. Aedes scutellaris simplex

Incubation Period

The incubation period is 3-14 days; commonly 7-10 days.

Period of Communicability

1. Patients are usually infective to the mosquito from a day before the febrile period

to the end of it.

2. The mosquito becomes infective from day 8 to 12 after the blood meal and

remains infective throughout its life.

Sources of Infection

1. Infected persons- the virus is present in the blood of patients during the acute

phase of the disease and will become a reservoir of the virus, sucked by

mosquitoes, which may then transmit the disease.

2. Standing water- any stagnant water in the household and its premises are usual

breeding places of these mosquitoes.

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Dengue Hemorrhagic Fever (DHF)

This severe form of dengue virus infection id manifested by fever, hemorrhagic,

diathesis, hepatomegaly and hypovolemic shock.

Classification According to Severity

Grade 1

There is fever accompanied with non-specific constitutional symptoms and the

only hemorrhagic manifestations is positive (+) in the tourniquet test.

Grade 2

All signs of Grade 1, plus spontaneous bleeding from the nose, gums,, and GIT,

are present.

Grade 3

There is the presence of circulatory failure, as manifested by a weak pulse, narrow

pulse pressure, hypotension, cold, clammy skin, and restlessness.

Grade 4

There is profound shock, and undetectable blood pressure and pulse.

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Complications

1. Dengue Fever

a. Epistaxis; menorrhagia

b. Gastrointestinal bleeding

c. Concomitant gastrointestinal disorder (peptic ulcer)

2. DHF

a. Metabolic acidosis

b. Hyperkalemia

c. Tissue anoxia

d. Hemorrhage into the CNS or adrenal glands

e. Uterine bleeding may occur

f. Myocarditis

3. Severe manifestations

Dengue encephalopathy is manifested by increasing restlessness, apprehension or

anxiety, disturbed sensorium, convulsions, spacity, and hyporeflexia.Reference: Handbook of Common Communicable and Infectious Disease, 3rd edition;Dionesia Mondejar-NavalesRN. Maed, p. 71-73

Vaccine

Dengvaxia, world’s first dengue vaccine was approved in Mexico. The Federal

Commission for the Protection against Sanitary Risks (COFEPRIS) has approved

Dengvaxia®, tetravalent dengue vaccine, for the prevention of disease caused by all four

dengue virus serotypes in preadolescents, adolescents and adults, 9 to 45 years of age

living in endemic areas.

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It took the multinational pharmaceutical company Sanofi Pasteur more than 20

years to develop the vaccine with clinical trials in five Asian and five Latin American

countries where dengue is endemic.

The vaccine was launched in the Philippines since it was the only country where

all three phases of the clinical development were conducted.

Health authorities said the vaccine will have side effects, including fever,

headache, muscle pain, weakness, redness and swelling.

The DOH also said that the medical breakthrough is no excuse to stop the fight

against dengue. Communities should work towards prevention by cleaning possible

mosquito breeding sites.

Health Secretary Janette Garin said the agency would get a discounted price for

the vaccine that would be used in the vaccination program starting March.

The DOH will begin vaccinating Grade 4 students in public schools in Metro

Manila, and in Southern and Central Luzon. The vaccine will be given in three doses,

with six-month intervals.

It will give the vaccine to over a million students this year but the health

department is planning to hold a nationwide vaccination on 2017.Reference: http://www.sanofipasteur.com/en/articles/dengvaxia-world-s-first-dengue-vaccine-approved-in-mexico.aspx; Lyon, France

- December 9, 2015

B. STATISTICS

Local

The number of dengue cases in the country spiked from around 120,000 in 2014

to over 200,000 in 2015.

Despite the sharp increase in dengue cases, the Department of Health (DOH) said

there was no corresponding increase in the number of deaths--with 598 in 2015 compared

to 465 in 2014.

The DOH estimated that some 220 Filipinos a day may be infected by the disease.

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http://cnnphilippines.com/videos/2015/04/20/DOH-Dengue-cases-on-the-rise.html

Reference: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4222740/ Lulu Bravo ,* Vito G. Roque, Jeremy Brett, Ruby Dizon, and Maïna L'Azou, 2014 Nov 6

International

The incidence of dengue has grown dramatically around the world in recent

decades. The actual numbers of dengue cases are underreported and many cases are

misclassified. One recent estimate indicates 390 million dengue infections per year (95%

credible interval 284–528 million), of which 96 million (67–136 million) manifest

clinically (with any severity of disease). Another study, of the prevalence of dengue,

estimates that 3900 million people, in 128 countries, are at risk of infection with dengue

viruses.

Member States in 3 WHO regions regularly report the annual number of cases. In

2010, nearly 2.4 million cases were reported. Although the full global burden of the

disease is uncertain, the initiation of activities to record all dengue cases partly explains

the sharp increase in the number of cases reported in recent years.

Other features of the disease include its epidemiological patterns, including

hyper-endemicity of multiple dengue virus serotypes in many countries and the alarming

impact on both human health and the global and national economies.

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http://www.ncbi.nlm.nih.gov/pubmed/?term=L'Azou%20M%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Dizon%20R%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Dizon%20R%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Brett%20J%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Roque%20VG%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Bravo%20L%5Bauth%5D

Cases across the Americas, South-East Asia and Western Pacific exceeded 1.2

million in 2008 and over 3 million in 2013 (based on official data submitted by Member

States). Recently the number of reported cases has continued to increase. In 2013, 2.35

million cases of dengue were reported in the Americas alone, of which 37 687 cases

were of severe dengue.Reference: http://www.who.int/mediacentre/factsheets/fs117/en/ May, 2015

C. SCOPE AND LIMITATION

We handled our patient last January 30, 2016 on our 6am to 2pm shift, bed #15,

Female-Ward at Laguna Medical Center under the supervision of Gloria Ramos,

Ph.D,MAN, RN.

We received the patient lying on bed with IVF Sodium Chloride 0.9 1 L on right

metacarpal vein. The exposure of our duty comprised Nurse-Patient-Interaction, Head-

to-Toe Assessment, IV regulation, vital signs monitoring and recording, drug

administration via oral route, IV drug medication study and charting.

To have further assessment, our group conducted a home visit on February 25,

2015 in the residence of Patient DLB in Lumban, Laguna. First and foremost, we asked

consent and stated the purpose of the home visit. As we gathered data and information

about the patient and his progress, the patient as well as the family members participated

and cooperated hospitably.

D. OBJECTIVES

General Objective:

At the end of the case study, the Level III nursing students will be able to

expound and incorporate all the ideas and knowledge gained to the nursing approach in

providing valid and outmost care connected with the patient diagnosed of Dengue

Hemorrhagic Fever.

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Specific Objectives:

As supported by our main objective, the level 3 student nurses will be able to:

1. Familiarize with the background of what Dengue Hemorrhagic Fever is all about;

2. Recognize predisposing and precipitating factors that may increase the development

of Dengue Hemorrhagic Fever;

3. Review and understand the Anatomy and Physiology of the Circulatory system and

Lymphatic system.

4. Explain and illustrate the pathophysiology of Dengue Hemorrhagic Fever;

5. Determine what specific laboratory results that may lead to Dengue Hemorrhagic

Fever;

6. Describe the potential complications related to Dengue Hemorrhagic Fever;

7. Develop a comprehensive nursing care plan, with a principle of SMART, that is

applicable to the client diagnosed with Dengue Hemorrhagic Fever;

8. Provide a well-develop Health Teaching using the METHODS formula to

promote positive continuity of care to the patient after discharge which would be in great

help for his continuity of care to the patient after discharge which would be in

great help for his condition.

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II. PATIENT’S PROFILE

Hospital Number: 137170

Patient’s Name: Patient DLB

Address: Segundo Pulo, Lumban, Laguna

Gender: Male

Birthday: 11/22/2001

Age: 14 y/o

Birthplace: Lumban, Laguna

Nationality: Filipino

Civil Status: Single

Religion: Roman Catholic

Educational Level: Grade 8

Allergies: (+) Penicillin

Admitting Time: 6:30am

Admitting Date: 01/29/16

Admitting Diagnosis: Severe Dengue

Admitting Physician: Dra. Abadier

Chief Complaint: Epistaxis, headache, nausea and vomiting

and body malaise

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III. PATIENT’S HISTORY

A. Past History

According to Patient DLB, he had experienced cough, cold, fever and

chicken pox before. He has no history of hospitalization but seeks medical

advice to clinics in their barangay and other clinic to the near towns.

B. Present History

5 days prior to admission, the patient experienced on and off fever. The

patient drinks tawa-tawa extract and antipyretic medications like biogesic and

tempra to relieve fever.

After a day, when the patient is still with fever, the patient decided to seek

medical attention in a small Clinic in Unson. They checked the platelet count

which is 187 X10/L and blood pressure of 100/80mmHg. Then he was given a

prescribed medication of Biogesic 500mg for his fever.

Two days prior to hospitalization, the patient is still with fever. He consults to

his paediatrician, Dra. Aquino and checked again for the platelet count that

has a result of 24 x10/L so he was advised to go to the hospital.

One day prior to admission, the patient was experiencing fever, loss of

appetite and epistaxis so the family decided to take him to Laguna Medical

Center, Sta. Cruz, Laguna.

January 29, 2016, at 6:30am he was admitted with a diagnosis of Severe

Dengue by attending physician Dra. Abadier with a blood pressure of

100/78mmHg.

Patient’s vital signs during our shift whereas follows:

Temperature: 38.2 °c

Pulse Rate: 98 bpm

Respiratory Rate: 20 cpm

Blood Pressure: 100/60 mmHg

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C. Psychological

Patient is unable to answer some of the questions properly because he

cannot recall what happened during hospitalization. Nevertheless, the patient

demonstrates an understanding and acceptance concerning on the health teaching

about the health condition he experienced.

D. Family History

There is no history of dengue cases within patient's family members except

with his two cousins who lived in the same Barangay.

E. Spiritual

Patient DLB’s religious affiliation is Roman Catholic. He stated that their

family do not usually go to church but always pray and ask guidance for them.

F. Sociocultural

The patient consults to hilot as one of their health care provider. Prior to

admission, patient DLB sipped tawa-tawa extract and had self-medication of advil,

biogesic, and tempra as a relieved for fever. He also consults in health care clinic

in their town.

G. Exercise

Patient is usually staying in their bedroom after school and during weekends.

But at times he used to walk in going to school that is about 1km away from their

residence.

H. Nutritional

The patient eats vegetables like radish, cabbage and mongo beans more

often than not. He said that he just consumes what is served by his mother and

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does not usually fond of eating junkfoods or processed foods. He drinks 6-8

glasses of water a day.

I. Developmental

Erik Erikson’s stages of psychosocial development are a comprehensive

psychoanalytic theory that identifies a series of eight stages, in which a healthy

developing individual should pass through infancy to late adulthood. All stages are

present at birth but only begin to unfold according to both natural scheme and one’s

cultural and ecological upbringing. Each stages builds upon the successful completion

of earlier stage.

STAGE DESCRIPTION RESULT JUSTIFICATION

Ages 12 to 18 years

old

Identity

Vs.

Role Confusion

The adolescent is

newly concerned

with how they

appear to others.

Superego identity is

the accrued

confidence that the

outer sameness and

continuity prepared

in the future are

matched by the

sameness and

continuity of one’s

meaning for oneself,

as evidenced in the

promise of a career.

It was attained by

the patient.

The patient

accomplished the

ability to settle in the

school. He ponders the

roles he wants to do in

the future. He knows

what he wants to do

and he expresses

himself in the way he is

known to be. He

manages to spend time

with his family and had

good relationship with

his classmates and

knows his priorities.

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J. Hygiene

Before Hospitalization During Hospitalization After Hospitalization

Patient takes a bath every

day before going to school

and brushes his teeth twice

a day. He performs hand

washing before meal and

he usually eat with the use

of spoon and fork instead

of the use of his bare

hands.

The patient is unable to go

to the bathroom by himself

due to muscle weakness so

the family members prefer

to perform sponge bath

when he was in the

hospital. He brushed his

teeth once a day and does

not wash his hands during

hospitalization.

The patient takes a bath

once a day and brushes his

teeth every morning and

before going to bed. He

demonstrates hand

washing with soap and

running water.

K. Elimination


Urination

The patient voids 5-6

times a day, yellowish in

color and with moderate

amount.

Defecation

Patient usually defecate

twice a day, light brown in

color and formed in

appearance.

Urination

Patient has no urinary

catheter inserted. He voids

3-4 times per shift,

transparent in color and

with an estimated amount

of 600 ml.

Defecation

During hospitalization, the

patient defecates 5-6 times

a day, black in color.

Urination

Patient voids 5-6 times a

day, approximately 600ml

and yellowish in color.

Defecation

The patient’s stool is light

brown in color and formed

in appearance. He

defecates twice daily.

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L. Sleep and Rest


Patient is able to sleep at 9

in the evening and wakes

up 5 in the morning to

prepare for school. He has

adequate rest every day.

The patient sleeps at 7pm,

but wakes up every time

he feels tenderness and has

uncomfortable sensation.

The patient is able to sleep

with his normal sleeping

pattern and has no

difficulty resting.

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IV. NUTRITIONAL ASSESSMENT

24 hour Food Recall

Before Hospitalization After Hospitalization

1. What time did you go to bed the night before?

Was this the usual time?

“I slept as early as 7pm but not continuous, sometimes I woke up when I feel uncomfortable.”

“No. I usually go to sleep around 9pm.”

Patient stated that he sleeps at 9pm in the evening.

“Yes.”

2. What time did you get up yesterday?

Was this the usual time?

When was the first time you had anything to eat or drink?

What did you have and how much?

“Around 8am.”

“No. I usually wake up earlier.”

“At lunch time.”

“Just a piece of biscuit and sipped as small amount of water.

“I woke up 6 in the morning.”

“Yes, it is.”

“I had my breakfast at 6:30am.”

“I ate a cup of rice and one hotdog.”

3. When did you eat again? “The next meal was my dinner.”

“I ate my snack at 10am.”

4. Where?

What and how much?

“In our house.”

“I drink a half glass of water and one spoonful of rice with egg pugo.”

“In our house.”

“I had 3 pieces of bread and one glass of ice tea.”

5. When did you eat next?

What did you eat and how much?

“At 10 pm.”

“A piece of tasty.”

“Lunchtime.”

“1 ½ cup of rice and sinigang.”

6. Did you eat or drink anything else?

“I had a glass of water and half bottle of gatorade.”

“Yes. I ate at 6:30 in the evening.”

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a. Anything from 1st meal to 2nd meal?

b. Anything from 2nd to 3rd meal?

c. Anything from 3rd meal to bed time?

“None.”

“None.”

“None.”

“I drink a glass of water about 150ml.”

“I drink a half glass of water.”

“I had a glass of water.”

7. Was this day’s food intake differing from usual?

If so, why?

“Yes.”

“I lose my appetite and feel nauseated every time I eat.”

“No.”

8. Is weekend eating different?

If so, why?

“Sometimes.”

“It depends on what food is available in our house.”

“At times.”

“It depends on what food is available in our house.”

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V. PHYSICAL ASSESSMENT

Area Method Findings Post-Findings InterpretationHair Inspection Hair is black

and equally distributed

Hair is black and equally distributed

Normal

Palpation No signs of tenderness and nodules while palpating

No signs of tenderness and nodules while palpating

Normal

Skin Inspection Generalized pallor

Presence of hematoma on the upper right arm

Dengue virus induces bone marrow suppression. Since bone marrow is the manufacturing center of blood cells its suppression causes deficiency of blood cells leading to low hemoglobin count.

Paleness is caused by reduced blood flow or a decreased number of red blood cells.

Reference: K. Kafeel (2011). Retrieved from: http://www.onlymyhealth.com/cause-low-

platelet-count-in-dengue-fever-1301653922

The presence of the virus (arbovirus) within the blood vessels, especially those feeding the skin, causes changes to these blood vessels. The vessels swell and leak because of increase capillary permeability. As the blood vessels become more damaged the blood vessels start to leak. When blood leaves the circulatory system and becomes stagnant, there is almost immediate clotting.

Reference: C. Dewit. Dengue Fever (2006). Retrieved from:

http://www.encyclopedia.com/topic/dengue_fever.aspx

C. Davis. Hematoma (2015). Retrieved from: http://www.emedicinehealth.com/hematoma/pag

e2_em.htm

Page | 17



Palpation Warm to touch With moist skin and with good skin turgor

Warm to touch because of the body’s compensation to the virus.The patient’s body temperature was 38.2 °c.Reference: W. Lloyd. (2013). Retrieved from:

http://www.healthgrades.com/symptoms/clammy-skin

Nails Inspection Nail surface is slightly curvedNo clubbed finger

Nail surface is slightly curvedNo clubbed finger

Normal

Palpation Capillary refill of more than 3 sec

With pale nail beds

Capillary refill of less than 3 secWith pinkish nail beds

Damage to an artery or vein allows blood to escape the circulatory system. Thus, a low hemoglobin count cause alteration in blood flow.

Eyes Inspection With pale conjunctiva

Pupil Equally Round Reactive to Light and AccommodationWith equally distributed eye lid and eye lashes

With moist and pinkish conjunctivaPupil Equally Round Reactive to Light and AccommodationWith equally distributed eye lid and eye lashes

Damage to an artery or vein allows blood to escape the circulatory system. Thus, a low hemoglobin count cause alteration in blood flow.

Palpation No signs tenderness when palpating

No signs tenderness when palpating

Normal

Ears Inspection Symmetrical, no presence of discharge or rednessCan react to soundNo presence of cerumen

Symmetrical, no presence of discharge or rednessCan react to soundNo presence of cerumen

Normal

Palpation No tenderness and nodules

No tenderness and nodules

Normal

Nose and

Sinuses

Inspection No nasal dischargeNo redness and

No nasal dischargeNo redness and

Normal

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inflammationNo nasal deviation

inflammationNo nasal deviation

Palpation No tenderness upon palpation

No tenderness upon palpation

Normal

Mouth Inspection Dry lips

With pale palate

Can able to move the tongue in all directionUvula is at the midlineNo presence of inflammation in oral mucosa

Moist and pinkish mucus membraneCan able to move the tongue in all directionUvula is at the midline

If the amount of fluid in the intravascular space is decreased, the body compensates. (fluid depletion)

Damage to an artery or vein allows blood to escape the circulatory system. Low hemoglobin count cause alteration in blood flow.

Palpation No tenderness when palpating for the soft and hard palateWith intact gag reflex

No presence of inflammation in oral mucosaNo tenderness when palpating for the soft and hard palateWith intact gag reflex

Normal

Neck Inspection No swelling and no venous distention

No swelling and no venous distention

Normal

Palpation No masses lymph nodes and thyroid gland enlargement

No masses lymph nodes and thyroid gland enlargement

Normal

Lungs and

Thorax

Inspection symmetrical anterior chest wall

symmetrical anterior chest wall

Normal

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With no difficulty of breathing

With no signs of difficulty of breathing

Normal

Percussion Resonance in sound

Resonance in sound

Normal

Auscultation With clear breath sounds

With clear breath sounds

Normal

With Systolic of 100 mmHg and Diastolic of 60mmHg

With systolic of 120 mmHg and Diastolic of 80

mmHg

Normal

Abdomen

Inspection No abdominal distention with no signs of tenderness or masses

No abdominal distention with

no signs of tenderness or

masses

Normal

Auscultation Bowel sound heardRLQ= 7RUQ= 6LUQ= 9LLQ= 8

Bowel sounds heard

RLQ= 5RUQ= 7LUQ= 5LLQ= 9

Normal

Percussion With tympanic With tympanic NormalPalpation Abdomen is

softWith no signs of tenderness or masses

Abdomen is softWith no signs of tenderness or masses

Normal

Muscle Inspection

and Palpation

Able to obey command

muscle strength of 4/5

Able to obey command

muscle strength of 5/5

The dengue virus causes of measurable muscle weakness.The muscle can move the joint it crosses through a full range of motion against gravity moderate resistance.

Extremi

ties

Inspection Presence of petechiae in upper and lower extremities

Has no signs of lesions

It caused by capillary fragility. The blood vessels start to leak and cause bleeding. Petechiae (small skin hemorrhages).

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VI. ANATOMY AND PHYSIOLOGY

Blood

Blood is made up of liquid (called plasma) and solid cells. Blood cells are made in

the bone marrow. Bone marrow is the soft, spongy substance in the centre of bones.

Structure

In adults, the most active bone marrow is found in the pelvic bone, shoulder

bones, back bones (vertebra), ribs, breast bone and skull. Immature blood cells in the

bone marrow are called stem cells. Stem cells can also be found in smaller amounts in the

bloodstream. These are called peripheral blood stem cells.

All of our blood cells develop from stem cells. The process of blood cell

development is called hematopoiesis. In the earliest stage of blood cell development,

stem cells begin to develop either along the lymphoid cell line or the myeloid cell line. In

both cell lines, the stem cells become blasts, which are still immature cells.

Lymphoid cell line

Lymphoid stem cells develop into lymphocytes (also called lymphoblasts).

Lymphocytes are another type of white blood cell (also called leukocytes). Lymphocytes

help fight infection and destroy abnormal cells.

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Myeloid cell line

Myeloid stem cells develop into red blood cells, platelets and some types of white

blood cells. Red blood cells carry oxygen to all tissues of the body. Platelets form clots in

damaged blood vessels to stop bleeding.

Myeloid stem cells develop into 2 different types of white blood cells, called

granulocytes and monocytes. These white blood cells destroy bacteria and other foreign

invaders and help to fight infection.

Functions

The main function of blood is to carry nutrients, gases, waste products, cells and

hormones. Each type of blood cell has a specific job.

Red blood cells carry oxygen from the lungs to the rest of the body. They also

carry carbon dioxide from the body to the lungs so it can be breathed out.

Platelets form blood clots in damaged vessels to stop bleeding.

White blood cells help prevent and fight infection by destroying bacteria, viruses

and other foreign cells or substances.

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Types of white blood cellsWhite blood cells are the cells that help the body fight infection. There are a

number of different types and sub-types of white blood cells which each have different

roles to play.

The three major types of white blood cells are: Granulocytes Monocytes Lymphocytes

Granulocytes

There are three different forms of granulocytes: Neutrophils Eosinophils Basophils

Granulocytes are phagocytes, that is they are able to ingest foreign cells such as

bacteria, viruses and other parasites.

Granulocytes are so called because these cells have granules of enzymes which help to

digest the invading microbes. Granulocytes account for about 60% of our white blood

cells.

Neutrophils are by far the most prevalent of these cells. Each neutrophil cell can

ingest up to between around 5 and 20 bacteria in its lifetime.

Eosinophils are involved in allergic reactions and can attack multicellular

parasites such as worms.

Basophils are also involved in allergic reactions and are able to release histamine,

which helps to trigger inflammation, and heparin, which prevents blood from clotting.

Monocytes

Monocytes can develop into two types of cell:

Dendritic cells are antigen-presenting cells which are able to mark out cells that are

antigens (foreign bodies) that need to be destroyed by lymphocytes.

Macrophages are phagocyte cells which are larger and live longer than neutrophils.

Macrophages are also able to act as antigen-presenting cells.

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http://www.diabetes.co.uk/diabetes-and-illness.html

Lymphocytes

Lymphocytes are cells which help to regulate the body's immune system.

The main types of lymphocytes are:

B lymphocytes (B cells) T lymphocytes (T cells) Natural Killer Cells

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VII. PATHOPHYSIOLOGY

Page | 25

Precipitating Factors Environmental conditions (open

spaces with water) Presence of 2 Dengue cases in

the community

Predisposing Factors Geographical area-tropical island

in the Pacific (Philippines)

Aedes Mosquito(Carrier of Dengue Virus)

Bite from mosquito to skin(Portal of Entry)

Virus will circulate in the blood

Infection primarily targets the reticulo endothelial

system (blood,bone marrow, lymph nodes)

Production of immune mediators

Activation of immune response

Destructive actions of the virus orbone marrow precursor cells

Release of cytokines

Stimulate WBC and Pyrogens

Fever 38.2°CViral replication and Cellular destruction

DENGUE HEMORRHGIC FEVER

URINARY TRACT INFECTION

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Muscle weakness

4/5

ThrombocytopeniaPlatelet Count=38x109/L

Low

LymphopeniaLymphocytes=2.29 %

Low

LeukopeniaWBC=3.83 x 109/L

Low

Capillary fragility Petechiae

GI Bleeding

MelenaRelease of Histamine↑ Capilliary permeability

Plasma leakage

Epistaxis

↑ Glomerular Permeabilty

↑ Amount of plasma protein

Urinalysis Result:(+) 4 protein2-4 hpf RBCFew Bacteria

Hemoglobin=86 g/L RBC=2.69x 1012/LHematocrit=23.9 %

VIII. MEDICAL MANAGEMENT

Date Doctor’s Order Interpretation

Day 1January 29, 2016,

6:30 am

EpistaxisDengue

Hemorrhagic fever

Typhoid fever

4:00 pm(+) epistaxis

Please admit to medicine ward

Secure consent

TPR every shift

DAT except dark colored food

Hospital policy designates the exact procedure that should be followed when admitting the patient to the holding area or operating room suite. Admission will help to monitor the client’s condition. The admitting procedure is continued with reassessment of the patient and allowance of time for last minute question. (references: Medical-Surgical Nursing 5th edition by Lewis, Heitkemper &Dirksen Chapter 17, page 380)

Informed consent is the patient’s autonomous decision about whether to undergo a procedure. Before signing the consent, the risks and benefits of the procedure must be explained in terms the patient could easily understand. This is to prepare patient psychologically and the health care workers from battery. (references: Maternal and Child Health Nursing 6th edition by Adelle Pilliteri Chapter 24, page 658 and Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 13th edition by Janice L. Hinkle & Kerry H. Cheever Chapter 17 page 406)

The recording of Temperature, Pulse rate, and Respiration are part of physical examination. Acute changes and trends over time are documented and unexpected changes and values that deviate significantly from a patient’s normal values are brought to the attention of the patient’s primary health care provider. (references: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 13th

edition by Janice L. Hinkle & Kerry H. Cheever Chapter 5 page 67)

Dark colored foods may alter the color of the stool of the patient. It is advice to patient which will undergo fecalysis exam to determine Blood Occult in the stools. Highly colored foods, dark green leafy vegetables and Iron supplements are avoided as these tend to interfere with the

Page | 27

TVF: D5LR 1L × 60

gtts/min × 2 cycles

Laboratories: Complete blood

count with PC, typing

Urine analysis

Hematocrit monitoring at every 6 hours

test. (reference: Nutrition and Diet Therapy for Nursing 2011 by Adela Jamorabo-Ruiz Chapter 13 page 301-302)

D5LR is an hypertonic solution that is given to prevent dehydration. Dengue is a disease of DEHYDRATION. Much like a Diarrhea except that the body fluids don’t come out with the patient’s stool but through PLASMA LEAKAGE. Imagine that the arteries and veins of a patient have thousands of pinpoint holes due to the body's reaction to the Dengue virus, causing the fluids inside the blood vessels to sip out. (reference: Fundamentals of Nursing 8th

edition of 2008 Volume 2 by Snyder, Berman, Kozier and Erb Chapter 52 Fluid, Electrolyte and Acid – Base Balance page 1456)

CBC is done to the patient to test if there is blood loss. To look for low platelet count typical of the later stages of the illness and to detect the decrease in hemoglobin, hematocrit, and red blood cell (RBC) count (evidence of anemia) that would occur with blood loss associated with severe dengue fever. (references: cell medicine, 24th edition by Golman and Schater page 345)

Urinalysis is done to the patient to detect possible abnormalities in the urinary tract. It is ordered to determine presence of bacteria or blood (hematuria) in the urine of the patient.( reference:Medical Surgical Nursing 8th edition volume 2, Chapter 45 Urinary System page 1150 )

A blood sample's hematocrit or the red blood cell volume percentage, and become a point of reference of its capability of delivering oxygen. The patient’s hematology result of Hct: 37.1 % as of 01-29-2016. (reference: retrieved from https://en.wikipedia.org/wiki/Hematocrit )

Page | 28

https://labtestsonline.org/understanding/conditions/anemia/

Medications: Ascorbic acid 500

mg 1 tab BID

Tranexamic acid 500 mg TIV every 8 hours x 3 days

For transfusion of platelet 6 units properly typed and cross matched

If platelet concentrate not cross matched may transfused FFP 4 units

Supplemental therapy in some GI diseases, during long term parenteral nutrition.Increases protectionmechanism of the immune system thus, resistance to infection. (Reference: Davis’s Drug Guide for Nurses fifth edition 2010 (ascorbic acid, page 105)

Inhibits activation of plasminogen thereby preventing the conversion of plasminogen to plasmin.Treatment for bleeding. Patient experienced epistaxis and melena. Reference: Davis’s Drug Guide for Nurses fifth edition 2010(tranexamic acid, page 1179)

Platelet transfusions are used to prevent spontaneous bleeding or to stop established bleeding in patients with a deficiency in platelet number or function. In Dengue patients, transfusion is done when platelet count is 10000-20000/ul and thrombocytopenic bleeding is present. All the patients of Dengue Shock syndrome require platelet support. The patient’s platelet revealed 8x 109/L as of 01-29-2016 and positive for epistaxis. Doctors use blood typing and cross matching to make sure that the patient receiving a blood transfusion is getting the correct type of blood. Crossmatching is used by a doctor to make sure that the specific donor blood that will be used during a transfusion does not react with a patient’s blood. (reference:http://ijtm.in/view_article.php?id=21)

Plasma contains all of the coagulation factors. Fresh frozen plasma (FFP) infusion can be used for reversal of anticoagulant effects. Plasma transfusion is recommended in patients with active bleeding. The patient experienced nose bleeding. FFP does not need to be cross-matched but should be ABO compatible. (reference: http://www.aafp.org/afp/2011/0315/p719.html)

Page | 29

Godex 1 cap 300 mg PO BID

Omeprazole 40 mg TIV OD

Ceftriaxone 1g TIV every 12 hours

Intake and output every shift

To prevent damage to liver, one of the complication of DHF. Godex acts by transporting excess, long-chain fatty acids into the mitochondria to produce high amounts of energy to produce high amounts of energy to provide cell protection and fast treatment of liver disease.(http://www.mergersdrugfil.com.ph/index.php/godex-ds )

Treatment and prevention of hypersecretions of stomach acid. Omeprazole is used to prevent upper gastrointestinal tract bleeding. Due to patient’s lost appetite with DHF it will cause abdominal pain. (retrieve from :http://www.mayoclinic.org/drugs-supplements/omeprazole-oral-route/description/drg-2006683)

To treat infection. Interferes with bacterial cell wall synthesis by inhibiting cross-linking of peptidoglycan strands. Peptidoglycan makes the cell membrane rigid and protective. Without it, bacterial cells rupture and die. The patient’s urinalysis revealed a presence of few bacteria in urine as of Jan. 31, 2016. (reference : Jones and Bartlett Nurse’s Drug Handbook 2015 (ceftriaxone page 223)

Accurate intake and output is necessary for determining fluid replacement needs and reducing risk of fluid overload and reflects circulating fluid shifts, and response to therapy. Dengue Hemorrhagic Fever can cause fluid shifting from intracellular spaces to intravascular space that leads to dehydration. (references: Nursing Care Plan 8th edition of 2010 by Marlynn E. Doenges Capter 10 page 542)

Page | 30

Vital sign every 1 hour and record

For close monitoring

Notify Dra. Abralzado

Refer

IVF to following D5LR 1L x 70 gtts/min x 2 cycles

Give Hydrocortisone 250 mg IV now

The vital signs are body temperature, pulse, respirations and blood pressure, which should be looked at in total, are checked to monitor the function of the body which may alter the normal function of the body.(Reference: Fundamentals of Nursing 8th Edition of 2008 Volume 1 by Berman, Snyder, Kozier and Erb Chapter 29 Vital signs page. 527)

The vital signs are body temperature, pulse, respirations and blood pressure, which should be looked at in total, are checked to monitor the function of the body which may alter the normal function of the body. Since the patient’s blood count especially the hemoglobin and platelet is decreasing he needs more attentive care.(Reference: Fundamentals of Nursing 8th Edition of 2008 Volume 1 by Berman, Snyder, Kozier and Erb Chapter 29 Vital signs page. 527)



Management for Dengue shock syndrome. Corticosteroids are potent anti-inflammatory agents that have a wide range of effects on immunological processes and have found use in a broad spectrum of diseases (Reference : Jones and Bartlett Nurse’s Drug Handbook 2015( hydrocortisone page 256)

Day 2January 30, 2016

3:00 am

Diphenhydramine 50 mg TIV now

To prevent allergic reaction after blood transfusion. Acts on blood vessels, GI, respiratory system by competing with

Page | 31

BP 100/70PR 86RR 21(-) PC

10:00 am(+) black stool

2:00 pm epistaxis

4:00 pmSevere dengue

Restless(+) epistaxis(+) petechia

(+) hematoma right forearm

Poor pulse(+) epigastric

tendernessClear breath

sounds

6:00 pmBP 126/79O2sat 99%Full pulses

Hydrocortisone 100 mg TIV now

Secure and transfuse 5 units platelet properly typed

Secure and transfuse either 5 units Platelet Concentrate or 5 units Fresh Frozen Plasma (whichever is available) properly typed and cross matched)

Regulate accurately present hydration rate

histamine for H1 –receptor site; decreases allergic response by blocking histamine. (Reference : Jones and Bartlett Nurse’s Drug Handbook 2015 ( diphenhydramine page 325)

Management for Dengue shock syndrome. Corticosteroids are potent anti-inflammatory agents that have a wide range of effects on immunological processes and have found use in a broad spectrum of diseases (Reference : Jones and Bartlett Nurse’s Drug Handbook 2015( hydrocortisone page 256)

Platelet transfusions are used to prevent spontaneous bleeding or to stop established bleeding in patients with a deficiency in platelet number or function. In Dengue patients, transfusion is done when platelet count is 10000-20000/ul and thrombocytopenic bleeding is present. All the patients of Dengue Shock syndrome require platelet support. Doctors use blood typing to make sure that the patient receiving a blood transfusion is getting the correct type of blood. (reference:http://ijtm.in/view_article.php?id=21)

Platelet transfusions are used to prevent spontaneous bleeding or to stop established bleeding in patients with a deficiency in platelet number or function. On the other hand,. Fresh frozen plasma (FFP) infusion can be used for reversal of anticoagulant effects. Plasma transfusion is recommended in patients with active bleeding. The patient experienced nose bleeding and presence of blood in the stool. (reference:http://ijtm.in/view_article.php?id=21, http://www.aafp.org/afp/2011/0315/p719.html)

To prevent dehydration causes by Dengue virus.

Page | 32

Facilitate paracetamol IV 150mg/ml PRN fever

Tepid sponge bath care out companion (please facilitate)

Hook to O2 support via nasal canulla x 3 cpm

Transfer to ICU please

Appraised mother

IVF to follow

Paracetamol is an antipyretics use to decreases fever by inhibiting the effects of pyrogens on the hypothalamus heat regulating centers & by a hypothalamic action leading to sweating & vasodilatation. (reference: retrieved from https://www.scribd.com/doc/36795690/Drug-Study-Paracetamol)

Tepid sponge bath is considered as one of the best cooling treatments. This method is recommended for febrile individuals, especially those with fever ranging from 102.2F or higher. It is effective in relieving fever by reducing high temperature and also helpful in alleviating pain or discomfort. (reference: https://www.scribd.com/doc/38235959/Tepid-Sponge-Bath)

Administration of oxygen helps increase the percentage of oxygen in inspired air. The goal of oxygen administration is to supply the patient with adequate oxygen to maximize oxygen carrying ability of the blood. Patient’s hemoglobin revealed 69 g/L (low). References: Medical Surgical Nursing by LweisHeitkemper Dirksen, Fifth Edition at pages 689)

Seriously ill patients require close observation and monitoring. Since the patient’s blood profile is continuously decreasing the doctor ordered to transfer him to ICU. (reference:http://www.cpmc.org/learning/documents/icu-ws.html)

The family should have an accurate knowledge about the medical condition of her child to alleviate stress. It allows the individual to accept and minimize reaction to difficult situations. (Reference: http://www.hindawi.com/journals/nrp/2011/392705/)

D5LR is an hypertonic solution that is

Page | 33

D5LR 1L x 70gtts 2 cycles

Omeprazole 40 mg IV OD

Fecalysis with occult

Tranexamic acid 500g IV run q 8

Vitamin K 1 amp IV every 8 hours

given to prevent dehydration. Dengue is a disease of DEHYDRATION. Much like a Diarrhea except that the body fluids don’t come out with the patient’s stool but through PLASMA LEAKAGE. Imagine that the arteries and veins of a patient have thousands of pinpoint holes due to the body's reaction to the Dengue virus, causing the fluids inside the blood vessels to sip out. (reference: Fundamentals of Nursing 8th


Treatment and prevention of hypersecretions of stomach acid. Omeprazole is used to prevent upper gastrointestinal tract bleeding. Due to patient’s lost appetite with DHF it will cause abdominal pain. (retrieve from :http://www.mayoclinic.org/drugs-supplements/omeprazole-oral-route/description/drg-2006683)

Since the patient was diagnosed of dengue hemorrhagic fever, these examination finds out to see if there was melena in the stool of the patient. ( reference: Brunner and Suddarth’s Textbook of Medical Surgical Nursing Twelfth Edition by Smeltzer, Bare, Hinkle and Cheever page 987)

Inhibits activation of plasminogen thereby preventing the conversion of plasminogen to plasmin.Treatment for bleeding. Patient experienced epistaxis and melena. (Reference: Davis’s Drug Guide for Nurses fifth edition 2010(tranexamic acid, page 1179)

To treat bleeding.The patient manifested epistaxis and black tarry stool at 2:00 pm as of Jan. 30, 2016. Required for hepatic synthesis of blood coagulation factors II (prothrombin), VII, IX, and X. An antihemorrhagic actor that promotes hepatic formation of active prothrombin.

Page | 34

Line no 1L PNSS 500cc then maintain at 55gtts/min (5 cycles)

Line no 2 D5LR 1L x 55gtts/min (5)

Refer for next IVF

For Fresh Whole Blood transfusion properly typed and crosmatched x 5 hrs 2 doses, 6hrs

Furosemide 20mg PO every after Blood transfusion

Please monitor vital sign blood

(Reference: Davis’s Drug Guide for Nurses fifth edition 2010 (vitamin K, page 970)

Used because it has little to no effect on the tissues and make the person feel hydrated preventing hypovolemic shock or hypotension. (reference: https://www.scribd.com/doc/109761163/PNSS-drug-study)



Plasma contains all of the coagulation factors. Fresh frozen plasma (FFP) infusion can be used for reversal of anticoagulant effects. Plasma transfusion is recommended in patients with active bleeding. The patient experienced nose bleeding. FFP does not need to be cross-matched but should be ABO compatible. (reference: http://www.aafp.org/afp/2011/0315/p719.html)

To prevent fluid overload that may be imposed by the additional blood volume delivered during transfusion. Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. (Reference: Davis’s Drug Guide for Nurses fifth edition 2010(Diuretics (Loop), page 392)

The vital signs are body temperature, pulse, respirations and blood pressure, which should be looked at in total, are

Page | 35

pressure every 1 hour and record

Refer

Hold vitamin K, and do please PT, PTT

Intake and output every shift

Complete blood count every 8 hours

Please include SGPT/SGOT ( Serum Glutamic Pyruvic Transaminase), SGOT ( Serum Glutamic

checked to monitor the function of the body which may alter the normal function of the body.(Reference: Fundamentals of Nursing 8th Edition of 2008 Volume 1 by Berman, Snyder, Kozier and Erb Chapter 29 Vital signs page. 527)

The PTT is used primarily to investigate unexplained bleeding or clotting. It may be ordered along with a prothrombin time (PT) test to evaluate hemostasis, the process that the body uses to form blood clots to help stop bleeding. These tests are usually the starting points for investigating excessive bleeding or clotting disorders. (reference: retrieved from https://labtestsonline.org/understanding/analytes/aptt/tab/test/)

Accurate intake and output is necessary for determining fluid replacement needs and reducing risk of fluid overload and reflects circulating fluid shifts, and response to therapy. Dengue Hemorrhagic Fever can cause fluid shifting from intracellular spaces to intravascular space that leads to dehydration. (references: Nursing Care Plan 8th edition of 2010 by Marlynn E. Doenges Capter 10 page 542)

CBC is done to the patient to test if there is blood loss. To look for low platelet count typical of the later stages of the illness and to detect the decrease in hemoglobin, hematocrit, and red blood cell (RBC) count (evidence of anemia) that would occur with blood loss associated with severe dengue fever. (references: cell medicine, 24th edition by Golman and Schater page 345)

Liver function tests are one of the blood tests that are performed to assess the function of the liver. Liver damage is detected initially by performing a simple blood test that determines the level of various liver enzymes present in the blood. Liver damage is one of the complication of Dengue Hemorrhagic Fever.(reference: retrieved from http://www.med-health.net/Sgot-Sgpt.html)

Page | 36

https://labtestsonline.org/understanding/conditions/anemia/

https://labtestsonline.org/understanding/conditions/hypercoagulable-disorders/

https://labtestsonline.org/understanding/conditions/hypercoagulable-disorders/

https://labtestsonline.org/understanding/conditions/bleeding-disorders/

https://labtestsonline.org/glossary/hemostasis

https://labtestsonline.org/understanding/analytes/pt

https://labtestsonline.org/understanding/analytes/pt

Oxaloacetic Transaminase) on next CBC extraction

O2 at 6 cpm via face mask

IVF line no. 1 PNSS at 55 gtts/min (5) x 2

fused no. 2 D5LR at 25gtts/min (2) x 2 hours

Refer

Administration of oxygen helps increase the percentage of oxygen in inspired air. The goal of oxygen administration is to supply the patient with adequate oxygen to maximize oxygen carrying ability of the blood. The patient’s hemoglobin revealed 69 g/L (low). (References: Medical Surgical Nursing by LweisHeitkemper Dirksen, Fifth Edition at pages 689)




Day 3January 31, 2016

12:29 am

BP 113/62PR 98T 37.4

O2sat 99%(+) mild headache

6:00 am

IVF line 1 PNSS at 25gtts/min x (2) x 4 hours

Line 2 D5LR at 25gtts/min (2) x 4 hours


D5LR is an hypertonic solution that is given to prevent dehydration. Dengue is a disease of DEHYDRATION. Much like a

Page | 37

BP 114/67(-) Bleeding

8:00 am(-) melena

(-) epistaxisAwake

ConfusedNo epigastric

tendernessFull pulse

Clear breath sounds10:00 pmCoherentFull pulse

No epistaxis

Refer

Paracetamol 1 amp 150mg/ml IV every 4 hours

Continue present management

Continue paracetamol PRN

Facilitate Fresh Whole Blood transfuse 2nd dose

Diarrhea except that the body fluids don’t come out with the patient’s stool but through PLASMA LEAKAGE. Imagine that the arteries and veins of a patient have thousands of pinpoint holes due to the body's reaction to the Dengue virus, causing the fluids inside the blood vessels to sip out. (reference: Fundamentals of Nursing 8th



For supportive Drug; supports body function until other treatments or the body’s treatments or body’s response can take over; because medication is a substance administered for the diagnosis, cure treatment or relief of symptoms of for prevention of disease. (Reference: Fundamentals of Nursing 8th Edition of 2008 by Berman, Synder, Kozier and Erb Chapter 35 Medications page 830


Plasma contains all of the coagulation factors. Fresh frozen plasma (FFP) infusion can be used for reversal of anticoagulant effects. Plasma transfusion is recommended in patients with active bleeding. The patient experienced nose

Page | 38

bleeding. FFP does not need to be cross-matched but should be ABO compatible. (reference: http://www.aafp.org/afp/2011/0315/p719.html)

Day 4February 01, 2016

8:30 am

Coherent BP 100/60

PR 9937

(-) Epistaxis9:30

(-) bleeding

PNSS 1L x 15 gtts/min (1)

D5LR 1L x 15 gtts/min (1)




Day 5 February 2, 2016 6:00 am

(-) bleedingPlatelet 198

May go home

Home Meds: Godex 1 cap

300mg BID x 5 days

Cefixime 200mg cap BID x 7 days

Discharge planning is the process of preparing a client to receive one level of care for another within or outside of the current health care agency; usually refers to the client leaving hospital for home.( Fundamentals of Nursing 8th Edition of 2008 by Berman, Synder, Kozier and Erb Chapter 7 Community-based nursing and care continuity page 113 )

To prevent damage to liver, one of the complication of DHF. Godex acts by transporting excess, long-chain fatty acids into the mitochondria to produce high amounts of energy to produce high amounts of energy to provide cell protection and fast treatment of liver disease.(http://www.mergersdrugfil.com.ph/index.php/godex-ds )

Cefixime is a cephalosporin antibiotic used

Page | 39

Omeprazole 20 mg cap OD

Ascorbic acid 500 mg tab OD

to treat infections such as urinary tract infections, because the patient’s urinalysis revealed presence of few bacteria in urine.(reference: retrieved from https://www.nlm.nih.gov/medlineplus/druginfo/meds/a690007.html)

Treatment and prevention of hypersecretions of stomach acid. Omeprazole is used to prevent upper gastrointestinal tract bleeding. (retrieve from :http://www.mayoclinic.org/drugs-supplements/omeprazole-oral-route/description/drg-2006683)

Supplemental therapy in some GI diseases, during long term parenteral nutrition.Increases protectionmechanism of the immune system thus, resistance to infection. (Reference: Davis’s Drug Guide for Nurses fifth edition 2010 (ascorbic acid, page 105)

VIX. LABORATORY TEST

Page | 40

Urinalysis

Date: Jan. 31, 2016

Provides important clinical information about kidney formation and help diagnose other diseases.

( Brunner and Suddarth’s Textbook of Medical Surgical Nursing 13th Edition by Smeltzer, Bare, Hinkle and Cheever chapter 53 Assessment of Kidney and Urinary Function page 1518 )

Test Reference Value

Result Implication

Physical Properties

Light Yellow

Normal

Transparency Slightly Hazy

Normal

Chemical PropertiespH 5 – 9 7.0 NormalSpecific Gravity 1.005 -

1.0301.015 Normal

Sugar Negative Negative NormalProtein Negative

(<10mg/dL/100ml)

+4 The glomerulus is the network of capillaries in the kidneys that filters low molecular weight solutes such as urea, glucose, and salts, but normally prevents passage of protein or cells from blood into filtrate. Due increased glomerular permeability; this permeability allows increased amounts of plasma proteins (sometimes very large amounts) to pass into the filtrate.

Reference: A.Shah. Proteinuria (2013) http://www.merckmanuals.com/professional/genitourinary-disorders/symptoms-of-genitourinary-disorders/proteinuria

Leukocytes Negative Negative NormalNitrite Negative Negative NormalUrobilinogen Normal Normal NormalBlood Negative Negative NormalKetone Negative Negative NormalBilirubin Negative Negative NormalAscorbic Acid Negative Negative NormalMicroscopic examinationRBC Negative 2– 4/hpf Due to increase in vascular permeability it

will leads to leakage of RBC.Reference: National Institute of Allergy and Infectious Diseases,

NIH: Volume 2

Pus Cells (WBC) Negative 2– 4/hpf Occurrence of pus cells in urine may be taken to be an indicator of an infection, either on the upper or the lower urinary

Page | 41

tract.( Retrieved from: http://www.newhealthguide.org/Pus-Cells-in-

Urine.html )

Mucus threads Few If they are present in large amounts then this means there is some underlying infection in any part of the urinary tract. If the mucus threads in urine are associated with red blood cells (blood), bacteria or yeast then this indicates to some sort of infection, irritation or other problems.

(Retrieved from: http://bestwebhealth.org/Mucus-Threads-In-Urine--What-Does-It-Mean-And-How-To-Treat.html )

Amorphous Phosphates

- -

Bacteria Negative Few Bacteria in urine can suggest infection due to vascular permeability.

Interpretation Nursing ResponsibilityPresence of protein, RBC and WBC in the urine cause by increase in capillary permeability thus permitting plasma protein and blood cells to pass into the urine.

1. Use clean container.2. Obtain first morning sample3. Immediately send specimen to the

laboratory with proper label.

( Medical Surgical Nursing 8th Edition page 1138 ) ( Medical Surgical Nursing 8th Edition page 1146 )

Complete Blood Count

Page | 42

Date: 01-29-2016

Test Result

Normal Range

Interpretation Implication

WBC 3.83 4.00-10.00 Low WBC is made in the bone marrow and circulates in the bloodstream. Dengue virus induces the suppression of the bone marrow that results of producing not enough WBC to defend against bacterial infections.

Reference: http://www.medicinenet.com/script/main/art.

asp?articlekey=6017

Neutrophils 2.52 2.00-7.00 NormalLymphocytes 0.83 0.80-4.00 NormalMonocytes 0.43 0.12-1.20 NormalEosinophils 0.04 0.02-0.50 NormalBasophils 0.01 0.00-0.10 Normal

Neu% 65.7 50.0-70.0 NormalLym 21.8 20.0-40.0 NormalMon 11.2 3.0-12.0 NormalEos 1.1 0.5-5.0 NormalBas 0.2 0.0-1.0 NormalRBC 4.43 4.00-5.50 NormalHGB 140 120-160 NormalHCT 40.0 40.0-54.0 NormalMCV 90.3 80.0-100.0 NormalMCH 31.6 27.0-34.0 Normal

MCHC 350 320-360 NormalRDW-CV 10.4 11.0-16.0 Low A low RDW means that the

red blood cells vary very little in size.Red cell distribution width (abbreviated as RDW) and Coefficient Variation (abbreviated as CV) is ameasurement of the amount that red blood cells vary insize. Red blood cells help carry oxygen in the blood.

Reference: http://www.medfriendly.com/red-cell-

distribution-width.html

RDW-SD 34.9 35.0-56.0 Low A low RDW means that the red blood cells vary very little in size.

Page | 43

http://www.medfriendly.com/abdominopelvic.html

http://www.medfriendly.com/lymphocyte.html

http://www.medicinenet.com/script/main/art.asp?articlekey=4286


Red cell distribution width (abbreviated as RDW) and

Standard Variation (abbreviated as SD) is a

measurement of the amount that red blood cells vary insize. Red blood cells help carry oxygen in the blood.

Reference:http://www.medfriendly.com/red-cell-


PLT 11 170-400 Low Dengue virus induces bone marrow suppression. Since bone marrow is the manufacturing center of blood cells its suppression causes deficiency of blood cells leading to low platelet count.

Reference:K. Kafeel (2011). Retrieved from:

http://www.onlymyhealth.com/cause-low-platelet-count-in-dengue-fever-1301653922

MPV 6.2 6.5-12.0 Low Mean platelet volume (MPV) reflects the average size of platelets present in a person's sample of blood. MPV is low with low platelet count due to dengue virus affecting production by the bone marrow.

Reference:https://labtestsonline.org/understanding/

analytes/platelet/tab/faq/

PDW 18.8 9.0-17.0 High Platelet Distribution Width (PDW) PDW is the variability in the size of platelets. Normally PDW increases with MPV. The patient shows a low MPV but a high PDW. Due to the bone marrow suppression.

Reference:https://allaboutblood.com/tag/pdw/

PCT 0.007 0.108-0.282

Low Low PCT (procalcitonin) values (<0.25 µg/L) in patients with clinical signs of infection (CAP, UTI) indicate a low probability for blood culture proof of bacterial infection. One major

Page | 44



advantage of PCT compared to other parameters is its early and highly specific increase in response to bacterial infections and sepsis.Reference:http://www.procalcitonin.com/default.aspx?

tree=_2_2

P-LCR 7.6 11.0-45.0 Low P-LCR means Platelet large cell ratio. It provides information about the underlying conditions of thrombocytopenia.

Reference:http://www.ehj.eg.net/article.asp?issn=1110-1067;year=2014;volume=39;issue=3;spage=

134;epage=138;aulast=Elsewefy

Date: 01-30-2016

Test Result Normal Range


WBC 4.86 4.00-10.00 NormalNeutrophils 1.65 2.00-7.00 Low Neutrophils are major players

in the body's defense against bacterial infections. Neutrophils are made in the bone marrow and circulate in the bloodstream. Dengue virus induces the suppression of the bone marrow that results of producing not enough neutrophils to defend against bacterial infections.

Reference: http://www.medicinenet.com/script/main/art.as

p?articlekey=6017

Lymphocytes 2.14 0.80-4.00 NormalMonocytes 1.05 0.12-1.20 NormalEosinophils 0.02 0.02-0.50 NormalBasophils 0.00 0.00-0.10 Normal

Neu% 33.9 50.0-70.0 Low Neutrophils are manufactured in bone marrow — the spongy tissue inside some of our larger bones. Anything that disrupts neutrophil production can result in neutropenia. The dengue virus induces bone

Page | 45


marrow suppression.Reference:

http://www.mayoclinic.org/symptoms/neutropenia/basics/causes/sym-20050854

Lym 44.0 20.0-40.0 High It is high because of the bacteria presence in the urine of the patient. Lymphocytes provide a means for immunity against antigens.

Reference:http://biology.about.com/od/cellbiology/ss/

lymphocytes.htm

Mon 21.6 3.0-12.0 High Monocytes play important roles in the immune defense, inflammation and tissue remodelling and it do so by phagocytosis, antigen processing and presentation and by cytokine production. It is high because of the bacteria presence in the urine of the patient.

Reference:http://www.monocytes.de

Eos 0.4 0.5-5.0 Low A low eosinophil level is usually not a cause for concern and is actually quite common. They are very helpful in defending the bodyagainst parasites. Eosinophils can be too low due to administration of steroids. Steroids are any of a large number of hormone substanceswith a similar and basic chemical structure. Hormones are natural chemicals produced by the body andreleased into the blood that have a specific effect on tissues in the body.The patient is administered by Hydrocortisone.

Reference: http://www.medfriendly.com/eosinophil.html

Bas 0.1 0.0-1.0 NormalRBC 2.22 4.00-5.50 Low Red blood cells circulate in the

blood and carry oxygen throughout the body. They are produced in the bone

Page | 46

https://labtestsonline.org/glossary/bone-marrow/

marrow and then released into the bloodstream as they mature. Dengue virus damage the bone marrow that results to low RBC production.


analytes/rbc/tab/test/

HGB 69 120-160 Low RBCs contain hemoglobin, which carries oxygen throughout your body. It is low because the patient experienced epistaxis and melena. It is low because the patient experienced epistaxis and melena. Moreover, the dengue virus induces bone marrow suppression

HCT 20.0 40.0-54.0 Low The hematocrit is routinely ordered as a part of the complete blood count (CBC). It may also be ordered by itself or with a hemoglobin level as part of a general health examination. It results from decrease production of hemoglobin and damage to bone marrow.


analytes/hematocrit/tab/test/

MCV 90.0 80.0-100.0 NormalMCH 31.1 27.0-34.0 Normal

MCHC 345 320-360 NormalRDW-CV 10.6 11.0-16.0 Low A low RDW means that the red

blood cells vary very little in size.Red cell distribution width (abbreviated as RDW) and Coefficient Variation (abbreviated as CV) is ameasurement of the amount that red blood cells vary insize. Red blood cells help carry oxygen in the blood.Reference: http://www.medfriendly.com/red-

cell-distribution-width.html

RDW-SD 34.8 35.0-56.0 Low A low RDW means that the red blood cells vary very little in

Page | 47



https://labtestsonline.org/understanding/analytes/hemoglobin/


https://labtestsonline.org/understanding/analytes/cbc



size.Red cell distribution width (abbreviated as RDW) and Standard Variation (abbreviated as SD) is ameasurement of the amount that red blood cells vary insize. Red blood cells help carry oxygen in the blood.Reference: http://www.medfriendly.com/red-


PLT 38 170-400 Low Dengue virus induces bone marrow suppression. Since bone marrow is the manufacturing center of blood cells its suppression causes deficiency of blood cells leading to low platelet count.



MPV 9.2 6.5-12.0 NormalPDW 18.9 9.0-17.0 High Platelet Distribution Width

(PDW) PDW is the variability in the size of platelets. Normally PDW increases with MPV. The patient shows a low MPV but a high PDW. Due to the bone marrow suppression.


PCT 0.035 0.108-0.282

Low Low PCT (procalcitonin) values (<0.25 µg/L) in patients with clinical signs of infection (CAP, UTI) indicate a low probability for blood culture proof of bacterial infection. One major advantage of PCT compared to other parameters is its early and highly specific increase in response to bacterial infections and sepsis.Reference:

http://www.procalcitonin.com/default.aspx?tree=_2_2

P-LCR 34.2 11.0-45.0 NormalDate: 01-31-2016

Test Result Normal Interpretation Implication

Page | 48



RangeWBC 5.91 4.00-10.00 Normal

Neutrophils 2.92 2.00-7.00 NormalLymphocytes 2.00 0.80-4.00 NormalMonocytes 0.96 0.12-1.20 NormalEosinophils 0.02 0.02-0.50 NormalBasophils 0.01 0.00-0.10 Normal

Neu% 49.5 50.0-70.0 Low Neutrophils are manufactured in bone marrow — the spongy tissue inside some of our larger bones. Anything that disrupts neutrophil production can result in neutropenia.

Reference:http://www.mayoclinic.org/symptoms/

neutropenia/basics/causes/sym-20050854

Lym 33.8 20.0-40.0 NormalMon 16.3 3.0-12.0 High Monocytes perform their

functions by surrounding and engulfing bacteria (a process known as phagocytosis). Monocytes can engage in phagocytosis by coating the foreign material with complement or antibodies.

High Monocytes happen for several reasons such as stress, inflammation, a fever from a virus, severe infection (because more macrophages are needed to fight it), premature cell death in living tissue, diseases that result from abnormal activity of the immune system, and regeneration of red blood cells.

Reference:http://www.medfriendly.com/monocyte.html

Eos 0.3 0.5-5.0 Low A low eosinophil level is usually not a cause for concern and is actually quite common. They are very helpful in defending the bodyagainst parasites. Eosinophils can be too low due to administration of steroids.

Page | 49

Steroids are any of a large number of hormone substanceswith a similar and basic chemical structure. Hormones are natural chemicals produced by the body andreleased into the blood that have a specific effect on tissues in the body.The patient is administered by Hydrocortisone.

Reference: http://www.medfriendly.com/eosinophil.html

Bas 0.1 0.0-1.0 NormalRBC 2.69 4.00-5.50 Low Red blood cells circulate in

the blood and carry oxygen throughout the body. They are produced in the bone marrow and then released into the bloodstream as they mature. Dengue virus damage the bone marrow that results to low RBC production.



HGB 86 120-160 Low RBCs contain hemoglobin, which carries oxygen throughout your body. It is low because the patient experienced epistaxis and melena. It is low because the patient experienced epistaxis and melena. Moreover, the dengue virus induces bone marrow suppression.



Page | 50










red blood cells vary very little in size.Red cell distribution width (abbreviated as RDW) and Coefficient Variation (abbreviated as CV) is ameasurement of the amount that red blood cells vary insize. Red blood cells help carry oxygen in the blood.

Reference:http://www.medfriendly.com/red-cell-


RDW-SD 35.0 35.0-56.0 NormalPLT 51 170-400 Low Dengue virus induces bone

marrow suppression. Since bone marrow is the manufacturing center of blood cells its suppression causes deficiency of blood cells leading to low platelet count.




(PDW) PDW is the variability in the size of platelets. Due to the bone marrow suppression.


PCT 0.046 0.108-0.282

Low Low PCT (procalcitonin) values (<0.25 µg/L) in patients with clinical signs of infection (CAP, UTI) indicate a low probability for blood culture proof of bacterial infection. One major advantage of PCT compared to other parameters is its early and highly specific increase in response to bacterial infections and sepsis.

Reference:

Page | 51



http://www.procalcitonin.com/default.aspx?tree=_2_2

P-LCR 34.7 11.0-45.0 Normal

Date: 01-31-2016



WBC 5.79 4.00-10.00 NormalNeutrophils 2.28 2.00-7.00 Normal

Lymphocytes 2.29 0.80-4.00 Low It is low because the dengue virus induces the bone marrow suppression.

Reference:http://biology.about.com/od/cellbiology/ss/

lymphocytes.htm

Monocytes 1.17 0.12-1.20 NormalEosinophils 0.05 0.02-0.50 NormalBasophils 0.00 0.00-0.10 Normal

Neu% 39.4 50.0-70.0 Low Neutrophils are manufactured in bone marrow — the spongy tissue inside some of our larger bones. Anything that disrupts neutrophil production can result in neutropenia.

Reference:http://www.mayoclinic.org/symptoms/

neutropenia/basics/causes/sym-20050854

Lym 39.6 20.0-40.0 NormalMon 20.2 3.0-12.0 High Monocytes play important

roles in the immune defense, inflammation and tissue remodelling and it do so by phagocytosis, antigen processing and presentation and by cytokine production. It is high because of the bacteria presence in the urine of the patient.

Reference:http://www.monocytes.de

Eos 0.8 0.5-5.0 NormalBas 0.0 0.0-1.0 NormalRBC 3.31 4.00-5.50 Low Red blood cells circulate in

the blood and carry oxygen throughout the body. They are produced in the bone marrow and then released into

Page | 52



the bloodstream as they mature. Dengue virus damage the bone marrow that results to low RBC production.



HGB 102 120-160 Low RBCs contain hemoglobin, which carries oxygen throughout your body. It is low because the patient experienced epistaxis and melena. It is low because the patient experienced epistaxis and melena. Moreover, the dengue virus induces bone marrow suppression






red blood cells vary very little in size.Red cell distribution width (abbreviated as RDW) and Coefficient Variation (abbreviated as CV) is ameasurement of the amount that red blood cells vary insize. Red blood cells help carry oxygen in the blood.Reference: http://www.medfriendly.com/red-


RDW-SD 35.3 35.0-56.0 NormalPLT 74 170-400 Low Dengue virus induces bone

marrow suppression. Since

Page | 53







bone marrow is the manufacturing center of blood cells its suppression causes deficiency of blood cells leading to low platelet count.




(PDW) PDW is the variability in the size of platelets. Normally PDW increases with MPV. Due to the bone marrow suppression.


PCT 0.071 0.108-0.282

Low Low PCT (procalcitonin) values (<0.25 µg/L) in patients with clinical signs of infection (CAP, UTI) indicate a low probability for blood culture proof of bacterial infection. One major advantage of PCT compared to other parameters is its early and highly specific increase in response to bacterial infections and sepsis.

Reference:http://www.procalcitonin.com/default.aspx?

tree=_2_2

P-LCR 35.4 11.0-45.0 Normal

Hematology

Page | 54

Date: 01-28-2016


Interpretation

Implication

Hemoglobin 16.4 13-17 NormalHematocrit 50.2 40-52% NormalRBC 5.45 4.7-6.1ml/

mm3Normal

WBC 2500 4800-10000/mm3

Low WBC is made in the bone marrow and circulate in the bloodstream. Dengue virus induces the suppression of the bone marrow that results of producing not enough WBC to defend against bacterial infections.


asp?articlekey=6017

DIFFERENTIAL COUNTNeutrophils 77 40-74% High Neutrophils are major players

in the body's defense against bacterial infections. Neutrophils are made in the bone marrow and circulate in the bloodstream. Dengue virus induces the suppression of the bone marrow that results of producing not enough neutrophils to defend against bacterial infections.


asp?articlekey=6017

Lymphocytes 21 20-40% NormalEosinophils - - -Monocytes 2 3-7% Low Monocytes are a type of white

blood cell that fight certain infections and help other white blood cells which is also regulate immunity against foreign substances. Monocytes are produced in the bone marrow and then enter the blood. A low number of monocytes in the blood (monocytopenia) can be

Page | 55

https://www.merckmanuals.com/home/blood-disorders/white-blood-cell-disorders/overview-of-white-blood-cell-disorders

https://www.merckmanuals.com/home/blood-disorders/white-blood-cell-disorders/overview-of-white-blood-cell-disorders




caused by anything that decreases the overall white blood cell count (see Neutropenia and see also Lymphocytopenia), such as a bloodstream infection or a bone marrow disorder.

Reference:https://www.merckmanuals.com/home/blood-

disorders/white-blood-cell-disorders/monocyte-disorders

Platelet count 24000 130-500000 Low Dengue virus induces bone marrow suppression. Since bone marrow is the manufacturing center of blood cells its suppression causes deficiency of blood cells leading to low platelet count.



Bleeding time - - -Clotting time - - -MCV 92.2 80-96FL NormalMCH 30.1 27-33PG NormalMCHC 32.7 32-36% Normal

Date: 01-29-16

Test Result Normal values


Hemoglobin - 11.5-14.8Hematocrit 37.1 38-44% Low The hematocrit is routinely

ordered as a part of the complete blood count (CBC). It may also be ordered by itself or with a hemoglobin level as part of a general health examination. It results from decrease production of hemoglobin and damage to bone marrow.

Reference:https://labtestsonline.org/understanding/analytes/hematocrit/tab/test/

Platelet count 18 250-510x10/L

Low Dengue virus induces bone marrow suppression. Since bone marrow is the

Page | 56




https://www.merckmanuals.com/home/blood-disorders/white-blood-cell-disorders/lymphocytopenia

https://www.merckmanuals.com/home/blood-disorders/white-blood-cell-disorders/neutropenia

manufacturing center of blood cells its suppression causes deficiency of blood cells leading to low platelet count.



Date: 01-29-16



Hemoglobin - 11.5-14.8 -Hematocrit 41.6 38-44% NormalPlatelet count 12 250-

510x10/LLow Dengue virus induces

bone marrow suppression. Since bone marrow is the manufacturing center of blood cells its suppression causes deficiency of blood cells leading to low platelet count.


http://www.onlymyhealth.com/cause-low-platelet-count-in-dengue-fever-

1301653922

Date: 01-30-16



Hemoglobin - 11.5-14.8 -Hematocrit 21% 38-44% Low The hematocrit is routinely

ordered as a part of the complete blood count (CBC). It may also be ordered by itself or with a hemoglobin level as part of a general health examination. It results from damage to bone marrow.

Reference:https://labtestsonline.org/understanding/analytes/hematocrit/tab/test/

Page | 57





Low Dengue virus induces bone marrow suppression. Since bone marrow is the manufacturing center of blood cells its suppression causes deficiency of blood cells leading to low platelet count.



1301653922

Date: 01-30-16



Hemoglobin - 11.5-14.8Hematocrit 35.7% 38-44% Low Hematocrit is the

amount of red blood cells in your blood. It is low because the patient experienced epistaxis and melena. Moreover, the dengue virus induces bone marrow suppression.





1301653922

Date: 01-30-16

Page | 58



Hemoglobin - 11.5-14.8 -Hematocrit 29.7% 38-44% Low The hematocrit is routinely

ordered as a part of the complete blood count (CBC). It may also be ordered by itself or with a hemoglobin level as part of a general health examination. It results from damage to bone marrow.







1301653922

Date: 02-01-2016



Hemoglobin 98 115-148 Low RBCs contain hemoglobin, which carries oxygen throughout your body. It is low because the patient experienced epistaxis and melena. It is low because the patient experienced epistaxis and melena. Moreover, the dengue virus induce bone marrow suppression.

Hematocrit 29% 38-44 Low The hematocrit is routinely ordered as a part of the complete blood count (CBC). It may also be ordered by itself or with a

Page | 59






hemoglobin level as part of a general health examination. It results from decrease production of hemoglobin and damage to bone marrow.



RBC 3.35 38-54 Low RBCs contain hemoglobin, which carries oxygen throughout your body. It is low because the patient experienced epistaxis and melena. Moreover, the dengue virus induces bone marrow suppression.

Platelet 88 250-510 Low Dengue virus induces bone marrow suppression. Since bone marrow is the manufacturing center of blood cells its suppression causes deficiency of blood cells leading to low platelet count.



1301653922

WBC 7-9 4-11 NormalSegmented neutrophils

52 45-55 Normal

Lymphocytes 40.3 38-45 NormalMonocytes 7-5 3-6 High Monocytes perform their

functions by surrounding and engulfing bacteria (a process known as phagocytosis). Monocytes can engage in phagocytosis by coating the foreign material with complement or antibodies.

High Monocytes happen for several reasons such as stress, inflammation, a fever from a virus, severe infection (because more

Page | 60


macrophages are needed to fight it), premature cell death in living tissue, diseases that result from abnormal activity of the immune system, and regeneration of red blood cells.

Reference:http://www.medfriendly.com/

monocyte.html

Date: 02-02-2016



Hemoglobin 96 115-148 Low RBCs contain hemoglobin, which carries oxygen throughout your body. It is low because the patient experienced epistaxis and melena. It is low because the patient experienced epistaxis and melena. Moreover, the dengue virus induces bone marrow suppression.

Hematocrit 26.8 38-44 NormalRBC 3.14 3.8-5.4 NormalMCV 85 80-100 NormalMCH 30.5 27-32 Normal

MCHC 359 320-360 NormalRDW-CV 13.5 11.0-16.0 NormalRDW-SD - 37-54 NormalPlatelet 198 250-510 Normal

PCT 0.188 0.15-0.50 NormalMPV 9.5 6-11 NormalPDW 18.6 11-18 NormalWBC 8.0 4-11 Normal

Segmented neutrophils

54.1 45-55 Normal

lymphocytes 38.3 38-45 Normalmonocytes 7.6 3-6

Date: 02-03-16



Page | 61

Hemoglobin 9.9 11.5-14.8 Low RBCs contain hemoglobin, which carries oxygen throughout your body. It is low because the patient experienced epistaxis and melena. It is low because the patient experienced epistaxis and melena. Moreover, the dengue virus induces bone marrow suppression.

Hematocrit 28.0 38-44% Low The hematocrit is routinely ordered as a part of the complete blood count (CBC). It may also be ordered by itself or with a hemoglobin level as part of a general health examination. It results from decrease production of hemoglobin and damage to bone marrow.


analytes/hematocrit/tab/test/.


Normal

Date: 02-03-16



Hemoglobin - 11.5-14.8 Low RBCs contain hemoglobin, which carries oxygen throughout your body. It is low because the patient experienced epistaxis and melena. It is low because the patient experienced epistaxis and melena. Moreover, the dengue virus induces bone marrow suppression.

Hematocrit 26.6 38-44% Low The hematocrit is routinely ordered as a part of the complete blood count (CBC). It may also be ordered by itself or with a

Page | 62






hemoglobin level as part of a general health examination. It results from decrease production of hemoglobin and damage to bone marrow.




Normal

TyphiDOT

Date: 01-29-16

Test Result

Salmonella IgG Negative

Salmonella IgM Negative

The patient TyphiDOT test is negative to Salmonella IgG and salmonella IgM.

The Typhidot test gave a sensitivity of 100 per cent and specificity of 80 per cent

when bacteraemic patients were analysed.

The TyphiDot is a DOT enzyme immunoassay that detects either IgM or IgG

antibodies against a specific antigen on the outer membrane protein of serotype Typhi.

Reference: https://www.researchgate.net/publication/10894775_Typhidot_test_to_detect_IgG_IgM_antibodies_in_typhoid_fever

DENGUE NS1 IgA/IgG/IgM

Date: 01-29-2016

Test Result

Page | 63


Dengue NS1 Positive

Dengue IgA Negative

Dengue IgG Positive

Dengue IgM Negative

The patient’s antibody test revealed positive in Dengue NS1 and Dengue IgG.

The non-structural protein 1 (NS1) of the dengue viral genome has been shown to

be useful as a tool for the diagnosis of acute dengue infections. Dengue NS1 antigen has

been detected in the serum of DENV infected patients as early as 1 day post onset of

symptoms (DPO), and up to 18 DPO.

Antibody tests, IgM and IgG- detect antibodies produced by the immune system

when a person has been exposed to the virus; these tests are most effective when

performed at least 7-10 days after exposure.

Reference:http://www.cdc.gov/dengue/clinicalLab/laboratory.html

https://labtestsonline.org/understanding/analytes/dengue/tab/sample/

BLOOD TYPE TEST

Date: January 29, 2016

ABO Rhesus DO (+)

X. PROBLEM PRIORITIZATION

Page | 64

https://labtestsonline.org/glossary/igg/

https://labtestsonline.org/glossary/igm/

1. Ineffective Tissue Perfusion

2. Hyperthermia

3. Imbalance Nutrition

4. Impaired Tissue Integrity

5. Risk for Injury

Page | 65

XI. NURSING CARE PLAN

Page | 66

Assessment Nursing Diagnosis

Planning Intervention Rationale Expected Outcome

O: Hemoglobin

results

revealed 69

mg/dl as of

01-30-16

BP: 100/60

mmHg

RR: 20 cpm

PR: 98 bpm

Headache

Generalized

pallor

Capillary

refill of

more than 3

sec

With pale nail

beds

With pale

Ineffective tissue perfusion related to decreased hemoglobin concentration in the blood.

After 8 hours of nursing intervention, the client will be able to:

Demonstrate different ways to improve blood oxygenation and circulation.

Verbalize understanding of condition and importance of treatment regimen.

Demonstrate increased tissue perfusion.

Monitor vital signs.

Elevate head of bed to about 10 degrees.

Discourage strenuous activities.

Provide health teaching regarding DHF.

Provide health teaching on drugs being taken.

Collaborative:

Administer Tranexamic Acid 50mg IV q8 as ordered.

Administer and

Serve as basis for any alteration in system functions.

To promote circulation and venous drainage.

To avoid increasing oxygen demand.

To help client understand his health condition.

To maintain compliance to meds.

To control bleeding.

Maintain hydration

After 8 hours of nursing intervention, the client was be able to:

Demonstrate different ways to improve blood oxygenation and circulation.

Verbalize understanding of condition and importance of treatment regimen.

Demonstrate increased tissue perfusion.

Page | 67

conjunctiva

and palate

Muscle

strength :

4/5

regulate IVF as ordered.

Administer packed RBC’s as ordered.

Monitor lab studies ( Hb, Hct, RBC count).

and help wash away toxins.

Packed RBC’s are adequate for stable patients with subacute/chronic bleeding to increase oxygen carrying capability

Aids in establishing blood replacement needs & monitoring for effectiveness of therapy.

Page | 68

Assessment Nursing Diagnosis Planning Intervention Rationale Expected Outcome

O: Temp: 38.2 °c

Warm to touch

Chills

Weak in

appearance

Easy fatigability

Dry lips

Pale

Hyperthermia related to presence of Arbovirus in patient’s body causing release of pyrogens.

After 2 hours of nursing interventions, the patient will be able to:

Manifest reduction of core temperature from 38.2 to a normal range of 36.5 C- 37.5 C

Monitor patient’s vital signs.

Note chronological and developmental age of client

Note presence/ absence of sweating.

Initiate tepid sponge bath.

Promotes surface cooling through undressing or removing extra linens.

Encourage adequate fluid intake.

Serves as base line data for future comparison.

Assess for causative/ contributing factor.

To assess degree of hyperthermia.

Facilitates heat through conduction and evaporation.

Facilitates heat loss by radiation.

To promote heat loss and hydration.

After 2 hours of nursing interventions, the patient will be able to:

Manifest reduction of core temperature from 38.2 to a normal range of 36.5 C- 37.5 C

Page | 69

Encourage adequate bedrest.

Instruct patient and SO to report signs and symptoms of hyperthermia like flushed skin, increasing respiratory rate and body temperature.

Collaborative: Administer

Paracetamol 1 amp IV, as ordered.

To reduce metabolic consumption and oxygen demands.

To promote wellness.

To relieve high temperature by inhibiting the synthesis of prostaglandin

Page | 70



S: “Wala akong ganang kumain“ as verbalized by the patient.

O: Lethargic

Easy

fatigability

Weak in

appearance

Had 2 crackers

in shift

Pale

24 hours dietary

recall

Imbalanced nutrition less than body requirements related to loss of appetite.

ST: within 4 hours of giving nursing intervention patient will be able to experience an increase in the amount or type of nutrients ingested.

LT: within 8 hours of giving nursing intervention and medical management patient will be able to experience adequate nutrition through oral intake.

Assess and document patient’s dietary history, patters of ingestion, intolerance to foods.

Auscultate bowel sounds.

Instructpt. on good oral hygiene before and after feedings.

Emphasize the importance of adequate

To determine daily nutrition needs.

Hypermotility of intestinal tract is common and is associated with vomiting and diarrhea, which may affect choice of diet/route.

To promote god appetite.

Promotes comfort to the patient and encourages a good

After giving effective nursing interventions patient will be able to partially demonstrate behavior, lifestyle changes to regain appropriate weight.

Page | 71

nutrition.

Promote pleasant relieving environment including socialization.

Collaborative:

Monitor BUN, protein, prealbumin, or albumin, glucose, nitrogen balance as indicated.

Advance diet as tolerated, avoid dark colored foods.

eating habit.

For education of the patient for appropriate recovery from nutritional imbalance.

Reflects organ function and nutritional status and needs.

Careful progression of diet when intake is resumed reduces risk of gastric irritation and to provide accurate assessment in stool.

Page | 72

Assessment Nursing Diagnosis Planning Intervention Rationale Expected Outcome

O: Temp: 38.2 °c

Hematoma on

the upper right

arm

Capillary refill

of more than 3

sec

Weak in

appearance

Dry lips

Headache-

Pain scale 5/10

Pale

Muscle strength :

4/5

Impaired tissue integrity related to mechanical and chemical factor of skin test and blood test; secondary to haematoma as evidence by collection of blood on the upper right arm.

After 4 hours of nursing interventions patient will demonstrate behavior to reduce the hematoma.

After 2 weeks of nursing interventions presence of hematoma will be reduce.

Provide comfortable environment.

Provide comfort measures by AM care, changing the linen and touch therapy.

Provide safety by placing pillows at the side of the bed.

Vital signs monitor and record.

To ease patient’s anxiety and to help the patient recover faster for proper hygiene of the patient.

For proper hygiene of the patient.

To avoid patient from injury.

To have baseline data.

After 4 hours of nursing interventions the patient shall have demonstrate behavior to reduce the hematoma.

After 2 weeks of nursing interventions the patient shall have no presence of hematoma.

Page | 73

Identify underlying condition involves in tissue injury.

Monitor laboratory studies.

Help patient and family to identify effective successful coping mechanism and to implement them.

Suggest treatment options, desire/ ability to protect self and potential self and potential to recurrence of tissue damage.

To changes indicative of healing or infection complications.

To reduce discomfort and improve quality of life.

Page | 74



O:

Weak in

appearance

Capillary refill

of more than 3

sec.

Easy fatigability

Hematoma at

the right upper

arm

Delirium

Platelet count

results revealed 8

x109/L as of 01-

30-16

Risk for injury related to abnormal blood profile as evidenced by decreased platelet count.

After 4 hours of nursing management, the patient will demonstrate behaviors to reduce risk factors and protect self from injury.

Establish rapport.

Monitor and record vital signs.

Assess mood, coping abilities, and personality styles (aggression and impulse behavior).

Observe for presence of petechiae, ecchymosis, bleeding from one more sites.

Maintain bed in a lowest position with wheels locked.

Advise SO that those self inflicting materials such as (utensils, knife and

To gain patient’s trust and cooperation.

For baseline data.

Aggressive and impulsive behavior indicates self harm to the patient.

Observing those signs will help to reduce the risk for injury to the other parts of the body.

Ensuring the patient’s safety.

To prevent further injury to the patient.

After 4 hours of nursing management the patient will demonstrate behaviors to reduce risk factors and protect self from injury.

Page | 75

syringes) should be keep.

Encourage the SO not to leave the patient unattended

Leaving the patient unattended may increase anxiety to the patient.

Page | 76

XII. DRUGS

Page | 77

Name of Drug Dosage and Frequency

Indications and Contraindications

Side Effects Mode of Action

Classification Nursing Responsibilities

Generic Name:Diphenhydramine

Brand Name:Benadryl

Date ordered:01-30-2016

50 mgPOTID

Peak: 15-60 minOnset: 1-4 hrDuration: 4-8 hr

Indication:To prevent allergic reaction after blood transfusion.

Transfusion reaction symptoms include: back pain blood in your urine chills fainting or dizziness fever flank pain skin flushing

Contraindications:Hypersensitivity to H 1 –receptor antagonist, acute asthma attack, lower respiratory tract disease, neonates.

Dizziness Drowsiness fatigue

anxiety Nausea

Acts on blood vessels, GI, respiratory system by competing with histamine for H 1 –receptor site; decreases allergic response by blocking histamine.

Antihistamine Medication may cause drowsiness. Advised the

patient to avoid activities requiring alertness until response of drug is unknown. Inform the patient

that this drug may cause dry mouth. Frequent oral

rinses, good oral hygiene, and candy that may minimize this effect. Teach patient and

significant other that this drug may cause drowsiness.

Reference : Jones and Bartlett Nurse’s Drug Handbook 2015 ( diphenhydramine page 325)

Page | 78


Indications and Contraindication

s

Side Effects Mode of Action Classification Nursing Responsibilities

Generic Name:Cefixime

Brand Name:Suprax

Date ordered:02- 02- 2016

200 mgPOBID

Peak: rapidOnset: 2-6 hrDuration: 24 hr

Indication:Treatment for infection.

The patient’s urinalysis revealed a presence of few bacteria in urine as of Jan. 31, 2016.

Contraindications:Hypersensitivity to cephalosporin or theirComponents.

Chills fever headache seizures Abdominal

cramps diarrhea elevated liver function

test results hepatic failure hepatitis hepatomegaly jaundice nausea

Interferes with bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands.Peptidoglycan makes cell membranes rigidand protective. Without it, bacterial cellsrupture and die.

Antibiotic Be aware that an allergic reaction may occur a few days after therapy starts.

Assess bowel pattern daily.

Assess for signs of superinfection, such as perineal itching, fever, malaise, redness, pain, swelling, drainage, rash, diarrhea, and cough or sputum changes.

Instruct patient and significant other to complete the prescribed course of therapy.

Tell patient and S.O. to report severe diarrhea to prescriber immediately.

Reference : Jones and Bartlett Nurse’s Drug Handbook 2015 (cefixime page 205)

Page | 79



Side Effects Mode of Action

Classification

Nursing Responsibilities

Generic Name:Ceftriaxone

Brand Name:Rocephin


1 gIV

every 12 hours

Peak: rapidOnset: end of infusionDuration: 12-24 hr

Indication:To treat infection.

The patient’s urinalysis revealed a presence of few bacteria in urine as of Jan. 31, 2016.

Contraindications:Hypersensitivity to ceftriaxone, othercephalosporins, or their components

Abdominal cramps

elevated liver function test results

Edema Arthralgia Allergic

pneumonitis,

dyspnea

Interferes with bacterial cell wall synthesisby inhibiting cross-linking of peptidoglycanstrands. Peptidoglycan makes the cellmembrane rigid and protective. Without it,bacterial cells rupture and die.

Antibiotic Assess bowel pattern daily.

Assess for pharyngitis, ecchymosis, bleeding, and arthralgia; they may indicate a blood dyscrasia.

Advise patient and S.O. to report any hypersensitivity reactions, such as a rash, itching skin, or hives, to prescriber immediately and to stop taking the drug.

Reference : Jones and Bartlett Nurse’s Drug Handbook 2015 (ceftriaxone page 223)

Page | 80

Name of Drug

Dosage and Frequency


Side effects Mode of Action Classification Nursing Responsibilities

Generic Name:Vitamin K

Brand name:Phytonadione


1 amp10mg/ml

IVevery 8 hours

Peak: 1-2 hrOnset: unknownDuration: unknown

Indication:To treat bleeding.

The patient manifested epistaxis and black tarry stool at 2:00 pm as of Jan. 30, 2016.

Contraindications:Hypersensitivity to benzyl alcohol (Aquamephyton only)

Gastric upset Unusual

taste Rash Urticaria Flushing Erythema Allergic

reactions

Required for hepatic synthesis of blood coagulation factors II (prothrombin), VII, IX, and X. An antihemorrhagic actor that promotes hepatic formation of active prothrombin.

Fat soluble vitamins Monitor the

patient for gastric upset.

Monitor patient for the possible side effects that may occur.

To report any signs and symptoms of allergic reactions.

Reference: Davis’s Drug Guide for Nurses fifth edition 2010 (vitamin K, page 970)

Name of Dosage and Indications and Side effects Mode of Action Classification Nursing

Page | 81

Drug Frequency Contraindications

Responsibilities

Generic Name: Omeprazole

BrandName:Losec

Ordered at:

01-29-166:30 am

01-30-1610:00 am

02-01-166:00 am

40 mg IVOD

Peak: unknownOnset: 10-90 minDuration: unknown

Indication:Treatment and prevention of hypersecretions of stomach acid.

Due to patient’s lost appetite with DHF it will cause abdominal pain.

Contraindications:Hypersensitivity

Weakness Dizziness Headache Fatigue Abdominal

pain Acid

regurgitation

Constipation

Diarrhea Flatulence Nausea Vomiting Rash Itching

Suppresses gastric secretion by inhibiting hydrogen; characterized as gastric pump inhibitor

Anti-ulcer, proton pump

inhibitor

Inform the patient and significant other about the reason why drug is given and how it is process inside the patient's body. Monitor for diarrhea and abdominal pain. Take the drug before meals. Report severe headache, worsening of symptoms, fever, chills. Swallow the capsules whole; do not chew, open, or crush them. Inform patient and S.O. that he/she may experience these side effects: Dizziness; headache; nausea, vomiting, diarrhea; symptoms of URI, cough.

Reference: Davis’s Drug Guide for Nurses fifth edition 2010 (omeprazole, page 878)

Page | 82

Name of Drug



Side effects Mode of Action


Generic Name:Tranexamic Acid

Brand Name:Cyklokapron

Ordered at:

01-29-166:30am

01-30-162:48pm

02-02-166:00am

500 mgIV

every 8 hours

Peak: 2-15 minutesOnset: intermittentDuration: 3 hrs.

Indication:Treatment for bleeding.Patient experienced epistaxis and melena.

Contraindication:Contraindicated to patients who are allegic to Tranexamic Acid.

DizzinessHypotensionNauseaVomitingDiarrhea

Inhibits activation of plasminogen thereby preventing the conversion of plasminogen to plasmin

Anti-fibrinolytic

agent Assess for

allergic reaction. Instruct patient

and S.O. to report untoward side effects.

Change the position of the patient slowly to prevent orthostatic hypotension.

Reference: Davis’s Drug Guide for Nurses fifth edition 2010 (tranexamic acid, page 1179)

Page | 83

Name of Drug

Dosage and

Frequency



Classification

Nursing Responsibilities

Generic name:Ascorbic acid

Brand name:Cecon

Date ordered:

01-29-166:30 am

02-02-166:00 am

500 mg1 tabOD

Peak: unknown Onset: unknownDuration: unknown

Indication:Dietary supplement

Contraindication:Hypersensitivity to tartrazine

Fatigue Headache Drowsiness Nausea Vomiting Diarrhea Flushing

Increases protectionmechanism ofthe immunesystem thus, resistance to infection.

Vitamin (water-soluble)

Assess for signs of vitamin C deficiency (gingivitis and bleeding gums.

Medication may cause drowsiness.

Advise patient to take this medication as directed and not to exceed dose prescribed.

Reference: Davis’s Drug Guide for Nurses fifth edition 2010 (ascorbic acid, page 105)

Page | 84

Name of Drug Dosage and

Frequency


Side Effects Mode of Action Classification Nursing Responsibilities

Generic Name:Hydrocortisone

Brand Name:Hydrocortone


100 mgIV

TID

Peak: unknownOnset: 15 minutesDuration: 6-12 hrs.

Indication:Management for Dengue shock syndrome.

Corticosteroids are potent anti-inflammatory agents that have a wide range of effects on immunological processes and have found use in a broad spectrum of diseases (Kehrl 1983).

Though, the use of corticosteroids in the management of dengue haemorrhagic fever and dengue shock syndrome is under debate.

Ataxia, behavioral

changes, depresssion, dizziness, euphoria, fatigue, headache, increased

intracranial pressure with papilledema,

insomnia, malaise, mood

changes, paresthesia, seizures, psychosis, syncope

Binds to intracellular glucocorticoidreceptors and suppresses inflammatory andimmune responses by inhibiting neutrophil and monocyte accumulation at inflammation site and suppressing their phagocytic and bactericidal activity stabilizing lysosomal membranes suppressing antigen response of macrophages and helper T cells inhibiting synthesis of cellular mediators of inflammatory response, such as cytokines, interleukins, and prostaglandins.

Adrenocorticoid replacement

Anti inflammatory

Monitor weight, blood pressure,and electrolyte levels regularly during therapy.

Expect hydrocortisone to worsen infections or mask signs and symptoms.

Caution patient to avoid people with infections because drug can suppress immune system, increasing risk of infection.

Page | 85

http://www.cochranelibrary.com/enhanced/doi/10.1002/14651858.CD003488.pub2#CD003488-bbs2-0016

http://www.cochranelibrary.com/enhanced/doi/10.1002/14651858.CD003488.pub2#CD003488-bbs2-0016

Reference:Guidelines for the

management of dengue fever & dengue haemorrhagic fever

in adults. (2012).http://

www.cochranelibrary.com/enhanced/doi/

10.1002/14651858.CD003488.pub2

Contraindications: Allergy to any

component of the drug.

Antibiotic-resistant infections.

Reference : Jones and Bartlett Nurse’s Drug Handbook 2015( hydrocortisone page 256)

Page | 86


Indications and Contraindication

s



Generic name:Paracetamol

Brand name:Acetaminophen

Date ordered:01-30-166:00 am

01-31-1612:29 am

02-02-166:00 am

1 amp150mg/mlIV every4 hours

PRN

Peak: 15 mins.Onset: unknownDuration: 4-6 hrs.

Indication:Fever

Contraindication:Hypersensitivity

Skin rashes Urticaria Hypoglycemi

a Leukopenia

Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever.

Antipyretic Assess patient for fever, note presence of associated signs (diaphoresis, tachycardia, ands malaise.

Be aware that long term use can cause liver damage.

Assess for allergic reactions.

Reference: Davis’s Drug Guide for Nurses fifth edition 2010 (acetaminophen, page 5)

Page | 87

Name of Drug





Generic name:Furosemide

Brand name:Lasix

Date ordered:01-30-164:00 pm

20 mgIV

every after blood

transfusion

Peak: 30-60 minuteOnset: 1-2 hrDuration: 6-8 hr

Indication:To prevent fluid overload that may be imposed by the additional blood volume delivered during transfusion.

Contraindication: Hypersensitivity to medication

Dizziness Headache Tinnitus Hypotension Nausea Vomiting Diarrhea Constipation Dry mouth Rashes

Inhibits the reabsorption

of sodium and chloride from

the loop of Henle and distal renal

tubule.

Loop diuretics

Monitor BP before and after administering the drug

Monitor for S&S of hypokalemia report muscle cramps on weakness to physician.

Make position changes slowly because high doses of antihypertensive drugs taken concurrently may produce episodes of dizziness or imbalance.

Instruct the patient and S.O. to report adverse reaction promptly, nausea, vomiting, diarrhea, appetite loss and visual disturbances may be indicators for drug toxicity.

Reference: Davis’s Drug Guide for Nurses fifth edition 2010 (Diuretics (Loop), page 392)

Page | 88

Name of Drug

Dosage and

Frequency


Side effects Mode of Action Classification Nursing Responsibilities

Generic name:Godex

Brand name:Cecon


1 cap 300 mgBID

x 5 days

Peak: unknownOnset: unknownDuration: unknown

Indication:To prevent damage to liver, one of the complication of DHF.

Dengue viral antigens have been found within hepatocytes, and the virus appears to be able to replicate in both hepatocytes and kupffer cells, and dysregulated host immune responses may play an important causative role in liver damage.

Source: HealthTap, https://www.healthtap.com/user_questions/532959-how-does-dengue-fever-leads-to-hepatomegaly

Contraindications:Hypersensitivity to medication

Nausea Vomiting Restlessness Anorexia Dysphagia Tachycardia

Chalagogues promotes the discharge of bile from the system, purging it downward.

Chalagogues- action that has the specific effect of stimulating the flow of bile from the liver.

Hepatic Protector

Maintain adequate hydration.

Reference: Retrieved from: http://www.thefilipinodoctor.com/search-drug-details.php?keyword=Legalon&id=20031380&secid=20030656&sec1id=20020016&sec2id=20030005&sec3id=&sec4id=

Page | 89

https://www.healthtap.com/user_questions/532959-how-does-dengue-fever-leads-to-hepatomegaly



https://www.healthtap.com/topics/virus

XIII. DISCHARGE PLAN

Medications:

Present to the significant other all the take home medicines. Give emphasis to

the brand and generic name, therapeutic and side effects as well as its daily

dose and proper route.

1. Godex 1 cap two times a day (BID) ,for 5 days

2. Cefixime 200 mg 1 cap two times a day (BID ) for 7 days

3. Omeprazole 20mg 1 cap once a day (OD)

4. Ascorbic acid 500 mg 1 tab once a day (OD)

Over the counter drugs may interfere with the effectiveness of the prescribed

drugs. It can also harm the patient if the drug is contraindicated.

Inform the family to seek medical help immediately if adverse reactions to

allergies occur.

Exercise:

Instruct to avoid excessive activities that may result to stress.

Just advised to perform range of motions and repetitive body movements for

promotion of optimum.

Treatment:

Remind to take the prescribed medicine, having a written reminder of the correct

medication, time to take, and the right frequency of the medicine on the way home to

establish assurance of medication compliance.

Health Teaching:

1. Encourage to have adequate rest periods

2. Advice the patient to minimize drinking coffee.

3. Explain the action and side effects of the drugs to the patient.

Page | 90

4. Instruct on proper intake of home medicines

5. Inform the patient about the new discovered Dengue vaccine (Dengvaxia).

Emphasize the importance of the acronym DENGUE:

D- discuss the possible source of infection of the disease.

E- educate the family/patient on how to eliminate those vectors.

N- never stocked water in a container without cover.

G- gallon, container and tires must have proper way of disposal.

U- use insecticides at home to kill or reduce mosquito.

E- encourage the family of the patient to clean the surroundings to

destroy the breeding places of mosquito.

Out – patient- department:

Instruct the patient and the guardian to have a check up or to consult physician

once a while to monitor patient’s condition and for detection of recurrences

and other complications that may rise on to it.

Diet:

Advise the patient to eat foods rich in iron such as green leafy vegetables

and animal organs like liver.

Instruct the family members to give the patient protein rich foods such as

meat, fish, eggs and nuts, vitamin K rich foods such as green leafy

vegetables, vit. C rich foods(guava and tomatoes and other citrus fruits),

carbohydrates rich food (breads and rice).

Advise to increase fluid intake to replace fluid loss.

Spiritual:

Encourage the patient to maintain his spiritual needs and advise to never

lose hope in any obstacle that he may encounter.

XIV. RECOMMENDATION

Page | 91

Our group recommends:

To our co- students

This study will help you to fully understand how dengue hemorrhagic fever

occurs, what are the symptoms and management to be given to patient with this type of

disease. You will also learn how risk factors such as people living or travelling to tropical

areas. This will serve as your guide in presenting case presentations in your future career.

To faculty members

This study will help you to recall all your knowledge and refreshes your idea

about dengue hemorrhagic fever. This may be helpful in teaching lessons of the faculty

members especially those who handle third year nursing students. We hope that this

would be a great help to all of you!

To our beloved readers

To our beloved readers who are curious about dengue hemorrhagic fever. This

will be very helpful to you because all the contents of this study were focused on the said

disease. Diet modifications and other health management to prevent occurrence of the

disease are also included.

XV. BIBLIOGRAPHY

Page | 92

A.Shah. Proteinuria (2013) http://www.merckmanuals.com/professional/genitourinary-disorders/symptoms-of-genitourinary-disorders/proteinuria

Brunner and Suddarth’s Textbook of Medical Surgical Nursing 13th Edition by Smeltzer, Bare, Hinkle and Cheever chapter 53 Assessment of Kidney and Urinary Function page 1518 )

C. Dewit. Dengue Fever (2006). Retrieved from: http://www.encyclopedia.com/topic/dengue_fever.aspx

C. Davis. Hematoma (2015). Retrieved from: http://www.emedicinehealth.com/hematoma/page2_em.htm

Dengue Cases. Lulu Bravo ,* Vito G. Roque, Jeremy Brett Ruby Dizon, and Maï L'Azou, 2014 Nov 6. Retrieved by: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4222740/

Dengue Incidence. Retrieved from: http://www.who.int/mediacentre/factsheets/fs117/en/ May, 2015

Dengvaxia. Lyon, France - December 9, 2015. http://www.sanofipasteur.com/en/articles/dengvaxia-world-s-first-dengue-vaccine-approved-in-mexico.aspx

Davis’s Drug Guide for Nurses fifth edition 2010

E. Esther. Typhoid Test (2009). Retrieved from: https://www.researchgate.net/publication/10894775_Typhidot_test_to_detect_IgG_IgM_antibodies_in_typhoid_fever

Handbook of Common Communicable and Infectious Disease, 3rd edition;Dionesia Mondejar-NavalesRN. Maed, p. 71-73

Jones and Bartlett Nurse’s Drug Handbook 2015

Laboratory Guideline and Diagnostic Findings (2010). Retrieved from: http://www.cdc.gov/dengue/clinicalLab/laboratory.html

M.Territo. Monocyte Disorders. https://www.merckmanuals.com/home/blood-disorders/white-blood-cell-disorders/monocyte-disorders

Med Friendly. Red Blood Cell. Retrieved from: http://www.medfriendly.com/red-cell-distribution-width.html

Medical Surgical Nursing 8th Edition page 1146

Neutropenia. Retrieved from: http://www.mayoclinic.org/symptoms/neutropenia/basics/causes/sym-20050854

Page | 93

http://www.ncbi.nlm.nih.gov/pubmed/?term=L'Azou%20M%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Brett%20J%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Roque%20VG%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Bravo%20L%5Bauth%5D

National Institute of Allergy and Infectious Diseases, NIH: Volume 2

K. Kafeel (2011). Retrieved from: http://www.onlymyhealth.com/cause-low-platelet-count-in-dengue-fever-1301653922

R. Bailey. Lymphocytes (2016). Retrieved from: http://biology.about.com/od/cellbiology/ss/lymphocytes.htm

Red Blood Cell Count. Lab Test Online. Retrived from: https://labtestsonline.org/understanding/analytes/rbc/tab/test/

White Blood Cell. Retrieved from: http://www.medicinenet.com/script/main/art.asp?articlekey=6017

World Health Organization (WHO) 2011. Retrieved from: http://who.int.com

Page | 94

dengue hemorrhagic fever- case study

Health & Medicine