OUR LADY OF LOURDES HOSPITAL

Clinical Practice Guidelines for DENGUE FEVER/

DENGUE HEMORRHAGIC FEVER

ER CONSULT
MEDICAL
Medical Assessment
History: Ask for history of moderate to high-grade fever of more than 2 days. Ask for
associated symptoms like headache, abdominal pain, myalgia, retro-orbital pain,
anorexia, gum or nose bleeding, spontaneous petecchiae, restlessness. Ask about level of
activity and ability to take liquid or solid foods, immunization history, exposure to others
with similar symptoms, previous medical consultation, lab results, tourniquet test done.
P.E.: Vital Signs: Temp / HR / RR / BP Weight / Height
General P.E. / Mental Status
Pay particular attention to the presence of petecchiael hemorrhages / bleeding
Diagnostics: CBC with platelet
Dengue confirmatory tests ( NS1 or Dengue Duo)
Assess: Severity of Dengue: Dengue suspect; Dengue Hemorrhagic Fever Grades I-IV
Disposition:
Send home if dengue suspect is active, and with good oral intake. Advise about
temperature control, increased oral fluids and need for follow-up daily until afebrile
for 3 days.
Admit if : Dengue suspect is sick-looking, with dehydration or with poor oral intake
Dengue Hemorrhagic Fever Grade I-IV
Anxious caregivers
NURSING
Nursing Assessment
TPR B/P Weight / Height
Teachings on Disease Processes
OUTCOMES
The caregivers / patient demonstrates understanding of:
1. Home Management – increased oral hydration and temperature control; need for daily
follow-up until afebrile for 3 days
2. Need for Hospital Admission

INITIAL WARD ADMISSION

MEDICAL
Complete the Admitting Diagnosis: Dengue Suspect; DHF Grade I-IV; indicate
concomitant clinical entities
Obtain consent for admission
Admit to room of choice. Inform AMD of admission.
Diagnostics: CBC with platelet count /Blood typing/ Urinalysis /
Optional: PTT/ PT / TPAG / ABGs/ Serum electrolyites / CXray
Therapeutic Interventions:
IVF depending on severity of DHF grading and state of dehydration; BP
Monitoring; Temperature control
NURSING
Nursing Assessment
TPR B/P Weight / Height
Assess for self-medications / drug adverse effects or allergies
Fasten identity bracelet / Red ID for allergy
Universal Precautions / Infection Control / Safety Measures / Fall Prevention
IV Therapy Monitoring
Complete Admission logbook
Introduce to Ward Routines
Teachings on Disease Process
OUTCOMES
The caregivers / patient demonstrates understanding of:
1. Plan of Care in the Ward
2. Monitoring for disease improvement / progression
FOLLOW-UP STAY IN THE WARD

MEDICAL
Monitor, assess and reassess patient’s state of dehydration; VS with emphasis on
Temperature, HR, BP, capillary refill time, fullness of pulses / Urine output / fluid
balance / weight / sensorium
Progress notes / proper endorsements
Serial lab work-ups as needed
Assess need for blood transfusion / antibiotics / albumin
If needed: Referral to specialist / Facilitate transfer to ICU or vice versa
Nutrition / modified diet with avoidance of brown-colored foods
Patient / family education on prevention of reinfection through vector control, regular
cleaning of environment and use of clothes and mosquito repellants
Prepare patient for possible discharge: 72 hours after defervescence with platelet count >
100,000 and rising; with improvement in appetite and general well-being
Provide complete and final diagnosis upon discharge

NURSING
Nursing Assessment
TPR B/P Weight / Height
Progress Notes / proper endorsements
Timely referral for problems / change in patient’s state
Patient education on prevention of reinfection
Explain to the patient home medications and schedule for follow-up.

OUTCOMES
The caregivers / patient demonstrates understanding of:
1. disease process of the patient
2. present status of the patient
3. discharge home medications and other supportive interventions at home
4. the need to follow-up with the AMD.

WHO Case Definitions

I. DENGUE FEVER
Probable: an acute febrile illness with 2 or more of the following:
Headache / retro-orbital pain / arthralgia / rash / hemorrhagic manifestations
Leukopenia AND
Supportive serology
Confirmed: A case confirmed by laboratory criteria
II. DENGUE HEMORRHAGIC FEVER
The following must all be present:
- fever, or history of acute fever, lasting 2-7 days, occasionally biphasic
- hemorrhagic tendencies, evidenced by at least one of the following:
(+) tourniquet test / petechiae, ecchymosis, purpura / hematemesis or melena
Bleeding from the mucosa, GIT, injection sites or other locations
- Thrombocytopenia (100,000 cells / mm3 or less)
- Evidence of plasma leakage due to increased vascular permeability, manifested by at
least one of the following: a rise in hct equal to or > than 20; a drop in hct
Following volume replacement treatment equal to or > than 20% of baseline
- signs of plasma leakage such as pleural effusion, ascites, hypoproteinemia
III. GRADING OF SEVERITY OF DHF / DSS:
Grade 1 – fever accompanied by nonspecific constitutional symptoms such as anorexia,
vomiting, abdominal pain; the only hemorrhagic manifestation is a (+) tourniquet test
and/or easy bruising
Grade 2 – spontaneous bleeding in addition to manifestations of grade 1 patients, usually
in the form of skin or other hemoorhages (mucocutaneous, GIT)
Grade 3 – circulatory failure manifested by a rapid, weak pulse and narrowing of pulse
pressure or hypotension, with the presence of cold, clammy skin and restlessness
Grade 4 – Profound shock with undetectable blood pressure or pulse
Grades 3 and 4 constitute DSS (Dengue Shock Syndrome)
 OUR LADY OF LOURDES HOSPITAL
Clinical Practice Guidelines for ACUTE DIARRHEA

ER CONSULT

MEDICAL
Medical Assessment
History: Ask for blood in stools, duration of diarrhea, # of watery stools/day, # of
vomiting episodes, presence of other symptoms, feeding practices, drug intake,
immunization history
P.E.: Vital Signs: Temp / HR / RR / BP Weight / Height
General P.E. / Abdominal / Mental Status
Diagnostics: Fecalysis
Assess: degree of dehydration: none / some (mild/moderate) / severe (WHO Table)
Etiology: viral / bacterial / amebic / others
Disposition:
Send home on ORS / antibiotics if needed / Zinc / Nutrition advise OR
Admit

NURSING
Nursing Assessment
TPR B/P Weight / Height
Teachings on Disease Processes
OUTCOMES
The caregivers / patient demonstrates understanding of:
1. Home Management – ORS / Zinc / Nutrition advise / antibiotics if needed
2. Need for Hospital Admission

INITIAL WARD ADMISSION

MEDICAL
Complete the Admitting Diagnosis: degree of dehydration / etiology of diarrhea
Obtain consent for admission
Admit to room of choice. Inform AMD of admission.
Diagnostics: Fecalysis / Urinalysis / CBC with platelet count
Optional: Serum electrolytes/ ABGs/ Stool CS/ Bun / Cr
Therapeutic Interventions:
ORS / IV Therapy following WHO guidelines
Continue breastfeeding
NPO if patient is obtunded or with severe vomiting
Supportive: Zinc / Probiotics (optional) / Nutrition advise
Antibiotics for Shigella, Ameba, Giardia, Cholera
NURSING
Nursing Assessment
TPR B/P Weight / Height
Assess for self-medications / drug adverse effects or allergies
Fasten identity bracelet / Red ID for allergy
Universal Precautions / Infection Control / Safety Measures / Fall Prevention
IV Therapy Monitoring
Complete Admission logbook
Introduce to Ward Routines
Teachings on Disease Process
OUTCOMES
The caregivers / patient demonstrates understanding of:
3. Plan of Care in the Ward
4. Monitoring for disease improvement / progression
FOLLOW-UP STAY IN THE WARD

MEDICAL
Monitor, assess and reassess patient’s state of dehydration
VS / Urine output / fluid balance / weight / improvement in appetite & sensorium
Progress notes / proper endorsements
Additional Lab work-ups as needed
Referral to specialist if course becomes complicated
Nutrition / food handling counselling
Advice on PPS recommended vaccines: measles / rotavirus
Prepare patient for possible discharge
Provide complete and final diagnosis upon discharge

NURSING
Nursing Assessment
TPR B/P Weight / Height
Progress Notes / proper endorsements
Timely referral for problems / change in patient’s state of hydration
Patient education on ORS / proper nutrition / hygiene
Explain to the patient home medications and schedule for follow-up.

OUTCOMES
The caregivers / patient demonstrates understanding of:
5. disease process of the patient
6. present status of the patient
7. discharge home medications and other supportive interventions at home
8. the need to follow-up with the AMD.

===============================================================

WHO TABLE FOR ASSESSING STATE OF DEHYDRATION

A B C
LOOK AT:
CONDITION Well, alert Restless, irritable Lethargic or
unconscious
EYES Normal Sunken Sunken
THIRST Drinks normally, not Thirsty, drinks Drinks poorly, or not
thirsty eagerly able to drink
FEEL: SKIN Goes back quickly Goes back slowly Goes back very
PINCH slowly
DECIDE The patient has NO If the patient has two If the patient has two
SIGNS OF or more signs in B, or more signs in C,
DEHYDRATION there is SOME there is SEVERE
DEHYDRATION DEHYDRATION
TREAT Use Treatment Use Treatment Use Treatment Plan
Plan A Plan B C URGENTLY
Management of Acute Diarrhea: Treatment Plans A, B & C

1. TREATMENT PLAN A:
Home therapy to prevent dehydration and malnutrition
 Give patient more fluids than usual.
 Zinc supplementation at 10-20 mg/day for 10-14 days
 Continue to breastfeed to prevent malnutrition.
 Bring back if there are signs of dehydration.

2. TREATMENT PLAN B:
Oral rehydration therapy for children with some dehydration.
 Amount of ORS to be given: child’s weight in kg x 75 ml.
 The child may be given more than the estimated amount of ORS if there are no signs of
overhydration.
 After four hours, reassess the child fully, following the guidelines in table 1.

NO SIGNS OF DEHYDRATION  Normal skin pinch

 Thirst has subsided
 Urine is passed
 Child becomes quiet and is no longer irritable and often falls
asleep
- Use Treatment Plan A and send home

Still has SOME DEHYDRATION Use Treatment Plan B again or Admit

 Mild  Normal or increased pulse
 Decreased urine output
 Thirsty
 Normal physical findings
 Moderate  Tachycardic
 Little or no urine output
 Irritable/ lethargic
 Sunken eyes and fontanel
 Decreased tears; dry mucous membranes
 Mild delay in elasticity (skin turgor)
 Delayed capillary refill (> 1.5 secs)
 Cool and pale

3. TREATMENT PLAN C: Severe Dehydration: Admit for IV Hydration

SEVERE DEHYDRATION
 Rapid and weak/or absent peripheral pulse
 Decreased blood pressure
 No urine output
 Very sunken eyes and fontanel
 No tears and parched mucous membranes
 Delayed elasticity (poor skin turgor)
 Very delayed capillary refill (> 3 secs)
 Cold, mottled
 Limp, depressed consciousness

IV Therapy:
- Start IV fluids immediately. If the patient can drink, give ORS by mouth until the
drip is set up. Give 100 ml/kg Ringer’s Lactate Solution or Normal Saline
divided as follows:
Age First give Then give
30 ml/kg in: 70 ml/kg in:
Infants (under 12 months) 1 hour 5 hours
Older 30 minutes 2 ½ hours

- If age is not known, the child can be given a fluid bous of 20 ml/kg of isotonic
fluid over 20 minutes. The child with severe dehydration will require several
boluses
- Reassess the patient every 1-2 hours. If hydration is not improving, give the IV
drip more rapidly.
After six hours (infants) or three hours (older patients), evaluate the patient using the
assessment chart. Then choose the appropriate Treatment Plan (A, B or C) to
continue treatment.
 OUR LADY OF LOURDES HOSPITAL
Clinical Practice Guidelines for URINARY TRACT INFECTION

ER CONSULT

MEDICAL
Medical Assessment
History: Ask for history of vomiting and fever in the older child; temperature instability,
poor feeding, vomiting, lethargy, jaundice in the neonate; Ask regarding previous
episodes of UTI and antibiotics given; age of toilet training, constipation, history of
instrumentation or dysfunctional voiding, family history of VUR (vesico-ureteral reflux)
and other renal illnesses in the family
P.E.: Vital Signs: Temp / HR / RR / BP Weight / Height BMI
General P.E. / Mental Status
Diagnostics: Urinalysis
Assess: Severity of UTI and presence of concomitant diseases like dehydration
Disposition:
Send home on antibiotics if older child, active, and compliant with antibiotic intake OR
Admit if neonate, sick-looking, with dehydration, unable to tolerate oral medications
NURSING
Nursing Assessment
TPR B/P Weight / Height
Teachings on Disease Processes
OUTCOMES
The caregivers / patient demonstrates understanding of:
1. Home Management – need to complete antibiotics and follow-up with AMD/specialist
2. Need for Hospital Admission

INITIAL WARD ADMISSION

MEDICAL
Complete the Admitting Diagnosis: Urinary Tract Infection (presumptive or culture-
proven); concomitant clinical entities
Obtain consent for admission
Admit to room of choice. Inform AMD of admission.
Diagnostics: Urinalysis / Urine CS / CBC with platelet count
KUB Ultrasound with pre- and post-void studies
If recurrent (optional): DMSA scan, VCUG, Bladder studies
Therapeutic Interventions:
IVF depending on state of hydration
Empiric antibiotics while awaiting C/S results
NURSING
Nursing Assessment
TPR B/P Weight / Height
Assess for self-medications / drug adverse effects or allergies
Fasten identity bracelet / Red ID for allergy
Universal Precautions / Infection Control / Safety measures / Fall Prevention
IV Therapy Monitoring
Complete Admission logbook
Introduce to Ward Routines
Teachings on Disease Process
OUTCOMES
The caregivers / patient demonstrates understanding of:
5. Plan of Care in the Ward
6. Monitoring for disease improvement / progression
FOLLOW-UP STAY IN THE WARD

MEDICAL
Monitor, assess and reassess patient’s state of dehydration
VS / Urine output / fluid balance / weight / improvement in appetite & general well-being
Progress notes / proper endorsements
Additional Lab work-ups as needed
Referral to specialist if course becomes complicated
Assess need to shift antibiotics based on culture results esp. if not responding; or from
intravenous to oral if improving
Nutrition / modified diet / potential food and drug interaction
Advice on Perineal hygiene esp for females / need for circumcision in males
Patient / Family education on need for long-term follow-up esp those with VUR
Prepare patient for possible discharge
Provide complete and final diagnosis upon discharge

NURSING
Nursing Assessment
TPR B/P Weight / Height
Progress Notes / proper endorsements
Timely referral for problems / change in patient’s state
Patient education on proper nutrition / hygiene
Explain to the patient home medications and schedule for follow-up.

OUTCOMES
The caregivers / patient demonstrates understanding of:
9. disease process of the patient
10. present status of the patient
11. discharge home medications and other supportive interventions at home
12. the need to follow-up with the AMD.
 OUR LADY OF LOURDES HOSPITAL
Clinical Practice Guidelines for COMMUNITY-ACQUIRED PNEUMONIA (CAP)

ER CONSULT

MEDICAL
Medical Assessment
History: Ask for history of cough and fever, difficulty of breathing, presence of other
symptoms, level of activity and ability to take food, drug intake, immunization history
P.E.: Vital Signs: Temp / HR / RR / BP Weight / Height
General P.E. /Mental Status
Emphasis on Respiratory findings: tachypnea, retraction, head-bobbing, cyanosis,
grunting, apnea, rales, wheezes
Diagnostics: Chest Xray / CBC with platelet if needed
Assess: Risk classification for pneumonia-related mortality ( PCAP A, B, C or D )
Disposition:
PCAP A and B (minimal to low risk): Send home on antibiotics / Respiratory care /
nutrition advise
PCAP C and D (moderate to high risk): Admit
NURSING
Nursing Assessment
TPR B/P Weight / Height
Teachings on Disease Processes
OUTCOMES
The caregivers / patient demonstrates understanding of:
1. Home Management – completion of antibiotics and follow-up after 3-7 days
2. Need for Hospital Admission

INITIAL WARD ADMISSION

MEDICAL
Complete the Admitting Diagnosis: Pneumonia (PCAP C or D); Other Clinical Entities
( concomitant infections, state of hydration )
Obtain consent for admission
Admit to room of choice. Inform AMD of admission.
Diagnostics: CBC with platelet count / CXray (if not done at the ER)
If needed: ABG / Pulse Oximetry / ESR / CRP / Urinalysis / Fecalysis
Culture studies: Blood / sputum / Tracheal aspirate
Pleural fluid analysis
Therapeutic Interventions:
IVF / Antibiotics (based on PCAP guidelines)
Oxygen therapy / Bronchodilators / Mucolytics
Nutritional support :NPO if patient is intubated or in severe respiratory
distress
Respiratory support – intubation and ventilator therapy if needed
Referral to a specialist if needed
NURSING
Nursing Assessment
TPR B/P Weight / Height
Assess for self-medications / drug adverse effects or allergies
Fasten identity bracelet / Red ID for allergy
Universal Precautions / Infection Control / Safety measures / Fall Prevention
IV Therapy Monitoring
Complete Admission logbook
Introduce to Ward Routines
Teachings on Disease Process
OUTCOMES
The caregivers / patient demonstrates understanding of:
7. Plan of Care in the Ward
8. Monitoring for disease improvement / progression
FOLLOW-UP STAY IN THE WARD

MEDICAL
Monitor, assess and reassess patient’s respiratory condition
VS with emphasis on normalization of RR, disappearance of retractions,
Grunting or apnea, defervescence within 72 hours, improvement in ability to feed,
sensorium, general well-being
Progress notes / proper endorsements
Additional Lab work-ups as needed
Referral to specialist if course becomes complicated
Nutrition Counseling
Advice on PPS recommended vaccines: Pneumococcal, Flu
Prepare patient for transfer to ICU from ward, or vice versa; or for possible discharge
when recovered
Provide complete and final diagnosis upon discharge

NURSING
Nursing Assessment
TPR B/P Weight / Height
Progress Notes / proper endorsements
Timely referral for problems / change in patient’s respiratory status
Patient education on respiratory care
Explain to the patient home medications and schedule for follow-up.

OUTCOMES
The caregivers / patient demonstrates understanding of:
13. disease process of the patient
14. present status of the patient
15. discharge home medications and other supportive interventions at home
16. the need to follow-up with the AMD.

Risk classification for Pneumonia-related mortality:

VARIABLES PCAP A PCAP B PCAP C PCAP D
Minimal Low risk Moderate High risk
risk risk
1.Co-morbid None Present Present Present
illness
2.Compliant Yes Yes No No
caregiver
3.Ability to Possible Possible Not possible Not possible
follow-up
4.Presence of None None Moderate Severe
dehydration
5.Ability to feed Able Able Unable Unable
6.Age >11mos. > 11 mos. < 11 mos. < 11 mos.
7.Respiratory
rate > 50/min > 50/min > 60/min > 70/min
2-12 mos. > 40/min > 40/min > 50/min > 50/min
1-5 years > 30/min > 30/min > 35/min > 15/min
> 5 years
8. Signs of respiratory failure
a.retraction None None Intercostal/ Supraclavicular/
subcostal intercostal/subcostal
b.head bobbing None None Present Present
c.cyanosis None None Present Present
d.grunting None None None Present
e.apnea None None None Present
f.sensorium Awake Awake Irritable Lethargic/stuporous/comatose
9. Complications None None Present Present
ACTION PLAN OPD OPD Admit to Admit to critical care unit
Follow-up at Follow-up regular ward Refer to specialist
end of after 3 days or private
treatment room
 OUR LADY OF LOURDES HOSPITAL
Clinical Practice Guidelines for SYSTEMIC VIRAL INFECTION

ER CONSULT

MEDICAL
Medical Assessment
History: Ask for history of fever, its pattern and duration, and other associated
symptoms like cough and colds, diarrhea, vomiting. Ask about level of activity and
ability to take liquid or solid foods, immunization history, exposure to others with similar
symptoms
P.E.: Vital Signs: Temp / HR / RR / BP Weight / Height
General P.E. / Mental Status
Diagnostics: If needed, CBC with platelet
Assess: Severity of febrile illness
Disposition:
Send home if older child is active, and with good oral intake. Advise about temperature
control and use of Paracetamol
Admit if a neonate, or an older child who is sick-looking, with dehydration or unable to
tolerate oral medications
NURSING
Nursing Assessment
TPR B/P Weight / Height
Teachings on Disease Processes
OUTCOMES
The caregivers / patient demonstrates understanding of:
1. Home Management – temperature control and follow-up if no resolution of symptoms
2. Need for Hospital Admission

INITIAL WARD ADMISSION

MEDICAL
Complete the Admitting Diagnosis: Systemic Viral Illness. Indicate if a specific Viral
Infection is strongly considered ( e.g. Dengue fever ); state of dehydration if present
Obtain consent for admission
Admit to room of choice. Inform AMD of admission.
Diagnostics: CBC with platelet count / Urinalysis / Fecalysis if with GI symptoms
CXray if needed
Optional: Dengue test / Typhoid test / ESR / CRP
Therapeutic Interventions:
IVF depending on state of hydration
Temperature control; Paracetamol; Ibuprofen
NURSING
Nursing Assessment
TPR B/P Weight / Height
Assess for self-medications / drug adverse effects or allergies
Fasten identity bracelet / Red ID for allergy
Universal Precautions / Infection Control / Safety Measures / Fall Prevention
IV Therapy Monitoring
Complete Admission logbook
Introduce to Ward Routines
Teachings on Disease Process
OUTCOMES
The caregivers / patient demonstrates understanding of:
9. Plan of Care in the Ward
10. Monitoring for disease improvement / progression
FOLLOW-UP STAY IN THE WARD

MEDICAL
Monitor, assess and reassess patient’s state of dehydration
VS / Urine output / fluid balance / weight / improvement in appetite & general well-being
Progress notes / proper endorsements
Additional Lab work-ups as needed to rule out other disease entities
Referral to specialist if course becomes complicated
Nutrition / modified diet
Prepare patient for possible discharge
Provide complete and final diagnosis upon discharge

NURSING
Nursing Assessment
TPR B/P Weight / Height
Progress Notes / proper endorsements
Timely referral for problems / change in patient’s state
Patient education on proper nutrition / hygiene
Explain to the patient home medications and schedule for follow-up.

OUTCOMES
The caregivers / patient demonstrates understanding of:
17. disease process of the patient
18. present status of the patient
19. discharge home medications and other supportive interventions at home
20. the need to follow-up with the AMD.