Dengue is transmitted by the bite of an 0/08mosquito infected with any one of the four dengue viruses.

t
occurs in tropical and sub-tropical areas of the world. Symptoms appear 314 days after the infective bite. Dengue
fever is a febrile illness that affects infants, young children and adults (WHO)
For dengue nursing care plans click here
Other names of Dengue:
H-Fever (Hemorrhagic Fever)
Dengue Shock Syndrome
Breakbone Fever due to prominent muscle and joint pain
Dandy Fever
Dengue Fever/Dengue Fever Syndrome
s a tropical disease caused by different strains of dengue virus which are transmitted by Aedes Aegypti mosquitos. t
is an acute infectious disease characterized by severe pain behind the eye and the joints and bones and
accompanied by rash. No bleeding occurs.
Dengue Shock Syndrome
Medical emergency due to loss of plasma and requires immediate administration of VF to expand plasma volume.
Dengue Hemorrhagic Fever
Those cases with gross hemorrhages. A severe illness characterized by abnormal vascular permeability,
hypovolemia and abnormal blood clotting mechanism

Causative Agent
4 serotype of the dengue virus (1,2,3 and 4 Group B Arbovirus)
the 4 viruses are antigenically close to each other however, they only give partial cross protection after being
infected by any of them
Aedes Aegypti
Bite of the Female AedesAegypti (day biting, low flying, breeds in stagnant water, in urban areas). Why female? t is
because that they use the blood obtained for laying of eggs. t is the primary vector for the transmission of dengue.
Sources:
1. nfected Persons virus is present in the blood of patients during the acute phase of the disease and will
become a reservoir of the virus
2. Standing water will serve as a breeding place for the mosquitoes
Mode of transmission
By the bit of an infective Aedes Aegypti mosquito
Incubation Period
4-6 days (minimum: 3 days; maximum: 10days)
PathophysioIogy
Each of the 4 types of Dengue virus can cause either classical or dengue hemorrhagic fever.
Virus enters the blood stream
Neutralizing antibodies are produced principally against the virus type
Because of the production of antibodies, and the response of the immune system to the initial attack,
constitutional signs and symptoms are manifested
Because of the increasing antigen-antibody complex
1. ncreased capillary fragility brought about by a strong immune complex reaction the produce toxic substance
like histamine, serotonin and bradykinin which damages the capillary wall in an attempt to repair lesions,
clotting occurs DSSEMNATED NTRAVASCULAR COAGULATON
2. ncreased capillary permeability loss of plasma from intravascular space
3. Thrombocytopenia acute excessive consumption of platelets due to generalized intravascular clotting
4. Decreased blood coagulation factors initiated by lesions in the capillary wall
SIGNS AND SYMPTOMS OF DENGUE HEMORRHAGIC FEVER
Signs and symptoms depend on the Grade:
Grade I - (+) fever Iasting 3 - 5 days
Abdominal pain
Anorexia, nausea and vomiting
Pain behind the eyes
Joint pains
(+) eveidence of vascular changes
petechiae
Herman's sign general flushing of the skin

Grade II - signs and symptoms of Grade I + BIeeding
Gum bleeding, epistaxis, hematemesis, melena, hematochezia

Grade III - signs and symptoms of Grade II + CircuIatory faiIure
Hypotension, rapid but weak pulse

Grade IV - signs and symptoms of Grade III + Shock

Diagnosis
1. Clinical
1. Fever acute in onset, high and continuous, lasting for 7-10 days
2. Tourniquet test (Rumpel-Leede test)
test to determine capillary fragility
1. Presence of bleeding (petechiae, purpura, ecchymosis, epistaxis, gum bleeding, hematemesis, melena)
1. aboratory
1. thrombocytopenia 100,000/ mm3 or less
2. Hemoconcentration
a increase of at least 20% in the hct
steady rise in hematocrit
1. Confirmatory test
1. SeroIogic test simplest and most rapid method of confirming clinical diagnosis of dengue infection
2. IsoIation of the virus most reliable although this is complicated and requires time.

Treatment:
1. Symptomatic
2. No specific antiviral drugs
3. n most cases, early and most effective replacement of plasma loss with plasma expander and or fluid
electrolytes solution results in a favorable outcome.

For Dengue Fever Syndrome
a. OraI fIuid and eIectroIyte repIacement
- encouraged to prevent and correct dehydration which results from fever
b. For fever -
antipyretics like Acetaminophen but not aspirin
c. Hematocrit Determination
useful guide in therapy as this reflects the degree of plasma leakage and the need for V fluid
test is recommended daily until the 3
rd
until patient is afebrile for 1-2 days.
d. CIose surveiIIance - continuous monitoring of BP/Hct/PIateIet
For Dengue Shock Syndrome
1. VF (5% Dextrose in 0.3 NaCl is initially given)
2. Plasma volume expanders
3. During fluid reabsorption phase (decreasing Hct)
- slow down rate of administration of VF
- if fluid overload occurs, give Furosemide 1 mg/kg V stat doses
d. Oxygen is indicated for all patients in shock

For Dengue Hemorrhagic Syndrome
1. Blood Transfusion
1. when significant bleeding occurs
2. when platelet count is less than 50,000/mm3
- prepare fresh whole blood
- transfuse if active bleeding occurs and if hematocrit and hemoglobin level falls

1. Oxygen ndicated
Prognosis
1. Grade and Good
2. Grade Guarded
3. Grade V Serious
Nursing Intervention
1. ControI Measure
Eradication of mosquitoes by eliminating breeding places
1. Any disease or condition with hemorrhage is enough to cause alarm. mmediate control of hemorrhage enclose
observation of the patient for the vital sign leading to shock
2. For hemorrhage
1.
1. keep patient at rest during bleeding episodes
2. observe for signs of deterioration
3. control bleeding
4. For Shock
a. prevention is the best treatment
b. restore blood volume
Dengue is transmitted by the bite of an edesmosquito infected with any one of the four dengue viruses. t occurs in
tropical and sub-tropical areas of the world. Symptoms appear 314 days after the infective bite. Dengue fever is a
febrile illness that affects infants, young children and adults.
Symptoms range from a mild fever, to incapacitating high fever, with severe headache, pain behind the eyes, muscle
and joint pain, and rash. There are no specific antiviral medicines for dengue. t is important to maintain hydration.
Use of acetylsalicylic acid (e.g. aspirin) and non steroidal anti-inflammatory drugs (e.g. buprofen) is not
recommended.
Dengue haemorrhagic fever (fever, abdominal pain, vomiting, bleeding) is a potentially lethal complication, affecting
mainly children. Early clinical diagnosis and careful clinical management by experienced physicians and nurses
increase survival of patients.
Ineffective Tissue Perfusion
a. A mosquito which carries the dengue virus is called Aedesaegypti. The said mosquito comes in
contact with a person and bites the person. The dengue virus will flow through the blood stream
and destroys blood components. Patients with dengue often has decreased WBC, platelet &
hemoglobin count. Hemoglobin count is used to measure oxygen carrying capacity of the blood.
Hemoglobin carries oxygen. Therefore, if there is decreased hemoglobin, there is also decreased
oxygen that reaches the different tissues of the body.
Assessment Nursing
Diagnosis
Objectives Nursing Interventions RationaIe Expected
Outcome
Subjective:
(none)
Objective:
Decreased
WBC
Decreased
platelet
Decreased
HgB
Decreased
capillary refill
time
Dysrhythmias
Altered LOC
Fever
Chills
Diaphoresis
neffective
tissue
perfusion
related to
decreased HgB
concentration
in the blood
secondary to
DHF 1
Short Term:
After 4 hours of
N, the pt will
demonstrate
behaviours to
improve
circulation.
ong Term:
After 4 days of
N, the pt will
demonstrate
increased
perfusion as
appropriate
Establish Rapport
Monitor Vital Signs
Assess patient's condition
Note customary baseline
data
Determine presence of
dysrhythmias
Perform blanch test
Check for Homan's sign
Note presence of bleeding
Elevate HOB
Encourage quiet & restful
atmosphere
nstruct to avoid tiring
activities
Encourage light ambulation
Encourage use of relaxation
techniques
Administer medications
To gain pt's trust
To obtain baseline
data
To assess contributing
factors
For comparison with
current findings
To identify alterations
from normal
To identify / determine
adequate perfusion
To determine
presence of thrombus
formation
To determine risk of
anemia
To promote circulation
To promote comfort &
decrease tissue
O2demand
To decrease cardiac
workload
To enhance venous
return
To decrease tension
and anxiety level
To treat underlying
cause
The pt shall
have
demonstrated
behaviours to
improve
circulation
The pt shall
have
demonstrated
increased
perfusion as
appropriate
Hyperthermia
When a person comes in contact with a mosquito, Aedesaegypti, the dengue virus flows through the blood stream.
As the compensatory mechanism of the body, it will raise its temperature to allow the immune system to work better
and to deteriorate the condition of the invaders thus causing hyperthermia.
Assessment Nursing
Diagnosis
Objectives Nursing Interventions RationaIe Expected
Outcome
S> (none)
O>
> Temp of
39.8
> Flushed
skin
> Skin warm
to touch
> Chills
The pt. May
manifest
> ncreased
RR
>
Tachycardia
>
Convulsions
> Sweating
Hyperthermia Short Term:
After 4 hours of
N, pt's
temperature will
decrease from
39.8 to 37.
Long Term:
After 3 days of
N, the pt will
identify
underlying
factors &
importance of
treatment as well
as s/sx requiring
further evaluation
or intervention
Establish Rapport
Monitor Vital Signs
Assess neurologic
response, note LOC &
orientation, reaction to
stimuli, papillary reactions &
presence of seizures
Note presence / absence of
sweating
Wrap extremities with bath
towels
Provide TSB q 15 minutes
Apply local ice packs in
axilla
nstruct client to have bed
rest
nstruct client to increase
OF
Administer replacement
fluids
Administer antipyretics
Reassess temperature q 15
minutes
To gain pt's trust
To obtain baseline
data
To evaluate effects &
extent of hyperthermia
To monitor heat & fluid
loss
To minimize shivering
To reduce body
temperature
To reduce body
temperature in areas
of high blood flow
To reduce metabolic
demands / oxygen
consumption
To prevent
dehydration
To support circulating
blood volume and
tissue perfusion
To restore normal
body temperature
To determine
effectiveness of
interventions done
The pt shall
have a
decreased
body
temperature
from 39.8 to
37
The pt shall
have
identified
underlying
factors and
importance of
treatment as
well as s/sx
requiring
further
evaluation or
intervention
Source: WHO> Dengue

Focus Charting of F-DAR is intended to make the client and client concerns and strengths the focus of care. t is a
method of organizing health information in an individual's record. Focus Charting is a systematic approach to
documentation.
Three columns are usually used in Focus Charting for documentation:
Date and Hour;
Focus and;
Progress Notes.
The progress notes are organized into (D) data, (A) action, and (R) response, referred to as DAR (third column).
Here is an exampIe of a format of Focus Charting or F-DAR
Date/Hour Focus Progress Notes
3/7/20108:00pm Focus of care,
this may be:
a nursing
diagnosis
a sign or a
symptom
an acute
change in
the
condition
behavior
DataActionResponse
The Data Category
The data category is like the assessment phase of the nursing process. t is in this category that you
would be writing your assessment cues like: vital signs, behaviors, and other observations noticed from
the patient. Both subjective and objective data are recorded in the data category.
The Action Category
The action category reflects the planning and implementation phase of the nursing prosess and includes immediate
and future nursing actions. t may also include any changes to the plan of care.
The Response Category
The response category reflects the evaluation phase of the nursing process and describes the client's response to
any nursing and medical care.
Focus Charting SampIes
Listed below are sample focus charting for different problems.
Pain
The focus of this problem is pain. Notice the way the D,A,R were written.
Date/Hour Focus Progress Notes
5/20/20108:00pm Pain D:>Reports of sharp pain on the
abdominal incision area with a pain
scale of 8 out of 10
>Facial grimacing
>Guarding behavior
>Restless and irritable
A:
>Administered Celecoxib 200mg V
>Encouraged deep breathing
exercises and relaxation techniques
>Kept patient comfortable and safe
R:
>Patient reports pain was relieved
Hyperthermia
Date/Hour Focus Progress Notes
5/20/20108:00pm Hyperthermia D:>Temperature of 38.9
O
C via axilla
>Skin is flushed and warm to touch
A:>Tepid Sponge Bath (TSB) done
7:30pm
>Administered 250mg V
Paracetamol as per doctor's order
>Encouraged adequate oral fluid
intake
>Encouraged adequate rest
R:
10:00pm>Temperature decreased
from 38.9 to 37.1
O
C
Another Variation
This is DAR made by Jay-D Man of Slideshare.net. with some modifications made. This is a very good variation.
F1: Ineffective Breathing Pattern
D1: increase respiratory rate of 24 cpm
D2: use of accessory muscle to breath
D3: presence of nonproductive cough
F2: Hyperthermia
D1: skin warm and flush to touched
D2: increased body temperature of T= 38.9 degree Celsius/axilla


F3: Fatigue
D1: less movement noted
A: 9:00am
monitored v/s and charted
regulated VF and charted
morning care done
assessed patient needs and performed handwashing before handling the patient
advised SO to always stay on patient bedside
promote proper ventilation and a therapeutic environment
elevated the head of the bed (moderate high back rest)
provided comfort measures and provide opportunity for patient to rest
due meds given
9:30am
tepid sponge bath done
instructed SO to provide blanket and let patient wear loose clothing
F4: Discharge PIan (12:00nn)
D1: discharged order given by Dr.Name/Time
M advised SO to give the ff. meds at the right time, dose, frequency and route
E encouraged to maintain cleanliness of the house and surroundings
T advised to go to follow-up consultations on the prescribed date
H encouraged to do chest tapping to facilitate mobilization of secretion
O observed for signs of super infections such as fever, black fury tongue and foul odor discharges
D encouraged to eat fresh vegetables and fish
S advised to continue praying to God and hear mass on Sunday
2:00pm out of the room per wheelchair with improved condition
ConcIusion
Do you have another variation on how to do the F-DAR method? You can leave your comments below!
References:
A very helpful guide on F-DAR or Focus Charting via SlideShare.net
Fundamentals of Nursing by Kozier and Erbs
mage Source from here

Symptoms

Early symptoms of dengue hemorrhagic fever are similar to those of dengue fever, but after several days the patient
becomes irritable, restlessrestless, and sweaty. These symptoms are followed by a shockshock -like state.

Bleeding may appear as tiny spots of blood on the skin (petechiaepetechiae) and larger patches of blood under the
skin (ecchymosesecchymoses). Minor injuries may cause bleeding.

Shock may cause death. f the patient survives, recovery begins after a one-day crisis period.



Early symptoms include:

* Decreased appetite
* Fever
* Headache
* Joint aches
* MalaiseMalaise
* Muscle aches
* Vomiting

AcuteAcute phase symptoms include:

* Restlessness followed by:
o Ecchymosis
o Generalized rash
o Petechiae
o Worsening of earlier symptoms
* Shock-like state
o Cold, clammy extremities
o Sweatiness (diaphoretic)

Nursing Care PIan for Dengue Hemorrhagic Fever (DHF)


Assessment
Assessment is the initial phase of the nurse to obtain the required data before performing nursing care. assessment
in patients with "DHF" can be done with the interview technique, measurement, and physical examination. As for
step-stages include:
* dentify potential sources and are available to meet patient needs.
* Assess the patient's medical history.
* Assess the increase in body temperature, signs of hemorrhage, nausea, vomiting, no appetite, heartburn, sore
muscles and joints, signs of shock (rapid and weak pulse, hypotension, cold and moist skin, especially on the
extremities, cyanosis, agitation, decreased consciousness).


Nursing Diagnosis and Intervention

1. Disorders of body fluid volume is less than body requirements related to increased capillary permeability, bleeding,
vomiting and fever.

Objective: Disorders of body fluid volume can be solved
Result Criteria :
* Volume of body fluids back to normal

ntervention :
* Assess the patient's general condition and the condition
* Observation of vital signs (Temperature, Pulse)
Observation * signs of dehydration
* Observations drip infusion, and the location of the insertion of intravenous needles
* Balance fluid (the fluid input and output)
* Give the patient and family encourage patients to drink plenty
* nstruct the patient's family to change his clothes soaked in patients
sweat.