NCP of Tropical Disease: DHF

( Dengue Hemoragic Fever )

By. Ns. RR. Dewi Rahmawaty Aktyani Putri, S.Kep., MNS

Department of Adult Nursing

Bachelor Degree of Nursing
Faculty of Health Science– UMP
2016
 Introduction
 DHF is a major global health problem.
 Asia in the first ranks of number of patients with DHF each year.
 Indonesia as the highest of DHF cases in Southeast Asia and the second-highest in the world
after Thailand (Achmadi U, Sudjana P, Sukowati S, 2010).
 In Indonesia, the number of patients of DHF among January to February 2016 were 8487
patients and 108 for mortality (Indonesia Ministry of Health, 2016).
 Dengue is caused by infection with one of the four dengue viruses: dengue virus 1 (DENV-1),
DENV-2, DENV-3 and DENV-4
 Dengue fever and dengue hemorrhagic fever (DHF) are viral
diseases transmitted by Aedes mosquitoes, usually Aedes
aegypti.

 There are four types of this virus (serotypes 1 to 4) and are

closely related to one another.

 Recovery from infection by one provides lifelong immunity

against that serotype but confers only partial and transient
protection against subsequent infection by the other three.

 There is good evidence that sequential infection increases

the risk of more serious disease resulting in DHF.
 Dengue Haemorragic Faver (DHF)

“THE PRIMARY INFECTION”
An acute infectious viral disease (Arthtropod Boon Virus Grup B) which presence
of mosquito (usually Aedes aegypti) usually affecting infants and young.

“THE SECONDARY INFECTION”
DHF occur if someone has got the first dengue viral infection  gets
recurrent infection with different virus types within a certain period.

3/4/2018 4
 DHF vector

Aedes Aegypti (most dominant), Aedes Albopictus and Aedes Polynesiensis.

Characters of Aedes Aegypti :
1. A smallish (bertubuh kecil)
2. Dark mosquito with conspicuous white markings and banded legs (Warna dasar
hitam dengan paha bersisik putih dan tungkai bawah hitam)
3. The proboscis is all black although the palps are white tipped (Sungut bersisik hitam
meskipun kepala bersisik putih)
4. Wings are dark scaled (Sayap bersisik hitam)
5. Being able to fly up to 100 meters
 The mosquito flourishes during rainy seasons but can breed in water-
filled flower pots, plastic bags, and cans year-round.

 One mosquito bite can inflict the disease.

 Under optimal conditions, the egg of an Aedes mosquito can hatch into
a larva in less than a day.

 The larva then takes about four days to develop in a pupa, from which an
adult mosquito will emerge after two days.
 The development from egg to be mosquitoes are 9-10 days.
 Three days after the mosquito has bitten a person and taken in blood, it
will lay eggs, and the cycle begins again.
A dengue epidemic requires Pathofisiology
the presence of:

The virus enters the human body

The vector mosquito through the bite of aedes aegypti.
(usually Aedes aegypti).

release of substances anaphylatoxin, histamine

The dengue viral. and serotonin.

A large number of Resulting in intravascular fluid into the extravascular

susceptible human extravasation, thus the capillary wall permeability
hosts. increases.

Plasma leakage into the extravascular area.

hypovolemic shock
 DHF is currently diagnosed by the following
World Health Organization (WHO) criteria:
1. Fever or recent history of fever lasting 2–7 days.
2. Any hemorrhagic manifestation (most common): skin hemorrhages (petechiae, hematomas), epistaxis (nose bleed), gingival
bleeding (gum bleed), and microscopic hematuria, vaginal bleeding, hematemesis, melena, and intracranial bleeding.
3. Thrombocytopenia (platelet count of <100,000/mm3).
4. Evidence of increased vascular permeability.
5. A positive tourniquet test
6. Evidence of plasma leakage due to increased vascular permeability consists of at least one of the following:
• An elevated hematocrit ≥20% above the population mean hematocrit for age and sex.
• A decline in hematocrit after volume-replacement treatment of ≥20% of the baseline hematocrit.
• Presence of pleural effusion or ascites detected by radiography or other imaging method.
• Hypoproteinemia or hypoalbuminemia as determined by laboratory test
 DENGUE VIRUS INFECTION

Asymptomatic Symptomatic

Dengue
Haemorrhagic fever
Undiffrentiated fever Dengue fever
(viral syndrome) (syndrome)
(Plasma
Dengue Fever leakage)

Dengue Shock
Syndrome (DSS)
No Shock
Dengue
Haemorrhagic fever
 Symptoms include:
• Headache, high fever (continuous and lasting 2-7 days).
• Rash, evidence of hemorrhage in the body (Petechiae) and/or Purpura (Lesions).
• Muscle and joint pain.
• Dehydration.
• Nausea and/or Haematemesis (vomiting of blood).
• Epistaxis (Bleeding from the nose, mouth, or gums).
• Haematuria (Blood in Urine).
• Pain behind the eyes.
• Plasma leakage. Skin rash
• Respiratory distress.
• Black stools, or easy bruising are all possible signs of hemorrhage.
• This form of dengue fever can be life-threatening or even fatal.
 Rumple-Led/tourniquet test
The tourniquet test is
part of the new WHO
case definition for
dengue. The test is a
marker of capillary 1. Use adult size cuff on the upper arm.
fragility and it can be
used as a triage tool to 2. Pump the cuff to get the systolic and diastolic pressures.
differentiate patients 3. Inflate the cuff to a point midway between SBP and
with acute DBP and maintain for 5 minutes. (100 + 70) ÷ 2 = 85
gastroenteritis, for
mm Hg.
example, from those
with dengue. Even if a 4. Reduce and wait 2 minutes.
tourniquet test was
previously done, it 5. Count petechiae below antecubital fossa. See image at
should be repeated if It right.
was previously negative
and there is no bleeding
6. A positive test is 10 or more petechiae per 1 square inch
manifestation.
Next.....

Example :
Mr. A, Systolic Blood Pressure (SBP) is 120 mmHg, Diastolic
Blood Pressure (DBP) is 80 mmHg.
Tourniquet test procedures:
1. 120 + 80 = 200
2. Count of 200 / 2 = 100 mmHg
3. Inflate the cuff up to 100 mmHg
4. Maintain for 5 minutes.
5. Count petechiae below antecubital fossa.
DHF is classified by WHO into four grades of severity

• Fever • Spontaneous • Circulatory • Profound

accompanied bleeding in failure shock
by non- addition to manifested by a
the rapid, weak pulse with
specific manifestations and narrow-ing undetecta
constitutional of Grade I of pulse pressure ble blood
symptoms; patients, or hypotension, pressure
• the only usually in the with the or pulse.
hemorrhagic forms of skin presence of
or other cold, clammy
manifestation haemorrhages skin and
is a positive . restleeness.
tourniquet
test and/or
easy bruising.
 Laboratory Test

• Haemoglobin
Blood • Leukocytes
test • Haematocrit
• Thrombocyte

Serology • Lab test: Hemaglutination Inhibition (HI).

test • Primary infection: IgM (+), IgG (-)
• Secondary infection: IgG (+), IgM (+)
 Objective Data Subjective Data

Weak High body temperature, shivering, his face redden.

Heat or fever. Mucosal dry mouth, bleeding gums, tongue dirty.
Headache. Red spots appear on the skin (petekia), torniquet test (+),
Anorexia, nausea, thirst, painful epistaxis, ecchymoses, Hyperemia of the throat.
swallowing.
Epigastric tenderness.
Heartburn.
On palpation palpable enlarged liver and spleen.
Pain in muscles and joints.
Weary at the whole body. In shock (degree IV) rapid and weak pulse,
hypotension, cold extremities, anxiety, peripheral
Constipation. cyanosis, shallow breathing.
Nursing Diagnosis - Nursing Care Plan for Dengue Hemorrhagic Fever

1. Hyperthermia related to the dengue virus infection.

2. Risk for fluid volume deficit related to intravascular fluid into the
extravascular migration.
3. Risk for Shock Hypovolemic related to excessive bleeding, intravascular fluid
into the extravascular migration.
4. Risk for imbalanced Nutrition: Less Than Body Requirements related to
inadequate nutritional intake due to nausea and decreased appetite.
1. Hyperthermia related to the dengue virus infection.
Goal: Normal body temperature
Expected outcomes: The body temperature between 36-37 0C, muscle pain disappeared.
Intervention:
1. Assess the patient's body temperature
Rational: find an increase in body temperature, facilitate intervention.
2. Give warm compresses
Rational: reduce heat to heat transfer by conduction. Warm water is slowly control the heat removal
without causing hypothermia or shivering.
3. Provide / encourage patients to drink plenty of 1500-2000 cc / day (as tolerated).
Rationale: To replace fluids lost due to evaporation.
4. Instruct patient to wear clothes that are thin and easy to absorb sweat.
Rationale: To provide a sense of comfort and wear thin easily absorbs sweat and does not stimulate an
increase in body temperature.
5. Observation intake and output, vital signs (temperature, pulse, blood pressure) once every 3 hours or
as indicated.
Rationale: Early Detect hydrated and knowing fluid and electrolyte balance in the body. Vital Signs is a
reference to determine the patient's general condition.
6. Collaboration: intravenous fluid and drug delivery according to the program.
Rationale: Proper hydration is very important for patients with a high body temperature. Particular drug
to lower a patient's body heat.
2. Risk for fluid volume deficit related to intravascular fluid
into the extravascular migration.
Goal: Not voume fluid deficit
Expected outcomes: Input and output balanced, vital sign within normal limits, no sign of pre-shock.

Intervention:
1. Monitor vital sign every 3 hours / as indicated.
Rationale: Vital sign helps identify fluctuations in intravascular fluid.
2. Observation of capillary refill.
Rational: Indications adequacy of peripheral circulation.
3. Observation intake and output. Note the color of urine / concentration
Rationale: Decreased urine output with increased density concentrated suspected
dehydration.
4. Encourage to drink 1500-2000 ml / day (as tolerated)
Rationale: To meet the needs of the body fluids peroral
5. Collaboration: Intravenous Fluid
Rational: It can increase the amount of body fluid, to prevent hipovolemic shock.
3. Risk for Shock Hypovolemic related to excessive bleeding, intravascular
fluid into the extravascular migration.
Goal: Not voume fluid deficit
Expected outcomes: Input and output balanced, vital sign within normal limits, no sign of pre-shock.

Intervention:
1. Monitor vital sign every 3 hours / as indicated.
Rationale: Vital sign helps identify fluctuations in intravascular fluid.
2. Observation of capillary refill.
Rational: Indications adequacy of peripheral circulation.
3. Observation intake and output. Note the color of urine / concentration
Rationale: Decreased urine output with increased density concentrated suspected
dehydration.
4. Encourage to drink 1500-2000 ml / day (as tolerated)
Rationale: To meet the needs of the body fluids peroral
5. Collaboration: Intravenous Fluid
Rational: It can increase the amount of body fluid, to prevent hipovolemic shock.
4. Risk for imbalanced Nutrition: Less Than Body Requirements related
to inadequate nutritional intake due to nausea and decreased appetite.
Goal: No disruption nutritional needs.
Expected outcomes: There are no signs of malnutrition, indicating a balanced weight.
Intervention:
1. Review the history of nutrition, including food preferences
Rationale: Identify deficiencies, suspect the possibility of intervention.
2. Observation and record the patient's food intake
Rational: Supervise caloric intake / lack of quality food consumption.
3. Measure body weight each day (if possible)
Rational: Supervise weight loss / oversee the effectiveness of interventions.
4. Give food a little but often and or eating between meals
Rational: little food can reduce vulnerabilities and increase input also prevent gastric distention.
5. Give and oral hygiene aids.
Rationale: Increased appetite and input peroral
6. Avoid foods that stimulate and gassy.
Rationale: Reducing distention and gastric irritation.
 Bibliography

• Achmadi, U., Sudjana, P., Sukowati, S. (2010). Demam berdarah dengue, buletin
jendela epidemiologi vol 2. Pusat data dan surveilens epidemiologi: Kemenkes RI.
• Brunner & Suddarth. (2002). Keperawatan Medikal Bedah, Edisi 8. EGC: Jakarta.
• Doengoes, Marlyn E. (1992). Nursing Care Plans: Guidelines For Planning And
Documenting Patien Care, 3th. Ed. F.A Davis Company: USA.
• Kalayanarooj,
S. (2011). Clinical manifestations and management of
dengue/DHF/DSS. Tropical Medicine and Health; 39(4), 83-87.
• Kemenkes RI. (2016). Wilayah KLB DBD. Indonesian Ministry of Health, Jakarta.