UNIVERSITY OF PERPETUAL HELP-SYSTEM DALTA

Case Study
Dengue Hemorrhagic Fever
In Partial Fullfillment on the Requirements of the Subject Nursing Care Management (NCM) 102

Submitted By: Barretto, Trishia Eduardo, Katrina Mendenueta, Anne Jo Pableo, John Alexander

Submitted to:

December 19, 2011

Introduction A. Background of Case Dengue, the most common arboviral illness transmitted worldwide, is caused by infection with 1 of the 4 serotypes of dengue virus, family Flaviviridae, genus Flavivirus (single- stranded nonsegmented RNA viruses). Dengue is transmitted by mosquitoes of the genus Dengue fever is transmitted thru a day biting mosquito, the Aedes Aegypti that lays its eggs in clean, stagnant waters usually found in flower vases, cans, rain gutters, etc. Initial symptoms of fever, rash and headache ( dengue triad ) may mimic symptoms of flu. Dengue Hemorrhagic Fever is a severe form of the disease with symptoms of hemorrhage (bleeding) commonly from the nose and gums and/or passage of dark-colored stools. Initial dengue infection may be asymptomatic (50%-90%), may result in a nonspecific febrile illness, or may produce the symptom complex of classic dengue fever (DF). A small percentage of persons who have previously been infected by one dengue serotype develop bleeding and endothelial leak upon infection with another dengue serotype. This syndrome is termed dengue hemorrhagic fever (DHF), although dengue vasculopathy has been proposed as a better term, as fluid loss into tissue spaces can lead to prolonged shock and complications, including gastrointestinal bleeding, a greater fatality risk than bleeding per se. B. Rationale and Significance of Choosing the Case The latest Department of Health statistics showed that a total of 27,071 dengue cases have been recorded from January to June of 2011 with 40% of those affected belonging to the 1-10y/o age group. There have been 172 dengue-related deaths recorded during the same period. The impact of dengue is recognized not only in the Philippines but in other countries as well. Currently,

dengue hemorrhagic fever is one of the leading causes of hospitalization and death in children in many Southeast Asian countries, with Indonesia reporting the majority of dengue hemorrhagic fever cases. Of interest and significance in prevention and control, 3 surveillance studies in Asia report an increasing age among infected patients and increasing mortality rate. In fact, June 15 has been declared in a joint session of the 10th ASEAN Health Ministers Meeting held in Singapore as ASEAN Dengue Day. The Department of Health, Philippines has also designated June 2011 as Dengue Awareness month.

Chief Complain: Intermittent high grade fever (T > 40c ) for more than 5 days

Patient s Profile: Name: Sex: Age: Birth date: Birth Place: Religion: Marital Status: Race/Nationality: Father: Mother: Admission Date: Attending Physician: Admitting Diagnosis: Sullegue, Clowie Elaisha Female 1 year old 09/18/2010 Paraaque Catholic Child Filipino Blasito Sullegue Cheriene Acoyong Service: Pediatrics

Dec. 04, 2011 2:35pm Eleuterio De Leon, M.D.

Dengue Hemorrhagic Fever (DHF I)

Nursing History: Patient is apparently well until 4 days prior to admission (Dec. 01, 2011); mother verbalized that the patient was hot the night she came home from work, until later that night the patient developed a fever( T >40c ). The next morning the patient s temperature returns to normal again (T 37c ) after giving paracetamol, the mother decided to bring the patient to a health clinic in Kalinisan, Bacoor. During the visit, the doctor said that it was just a regular fever and was prescribed medicines (Tempra and Cefalexin). However the medications provided temporary relief and the patient s temperature started to increase again. Two days prior to admission the patient developed rashes, had difficulty of breathing and was restless. The patient started to scratched herself, so her parent s went to the district hospital where Paracetamol was administered by injection to patient s left deltoid area. The attending physician diagnosed the patients of having Dengue. However, the mother noticed a small bruise on the injection site, which later on developed as hematoma. They decided to bring the patient back to the district hospital only to be turned down by the physicians because of low platelet count (80) so they were referred to go to University of Perpetual Help Medical Center where the patient was admitted (Dec. 04, 2011 2:35pm) with Dr. Eleuterio De Leon as their attending physician.

Health Assessment I. Demographic Data (Biographic Data) Client s Name: Sullegue, Clowie Elaisha Age: 1 y.o. Marital Status: Child Religion: Catholic Address: Zapote, Las Pias Contact No.: 09208567790 Birth date and Place: 09/18/2010/ Paraaque Race/ Nationality: Filipino Health Care Financing: Phil Health/Personal Usual Source of Medical Care: Community Health Centers or Hospitals Source of Reliability of Information: internet, books, television and health care team Reasons for Seeking Health Care: Pinayuhan kasi kami ng doctor na magpa-admit dahil sa sakit ng anak ko, at gusto ko rin na maka-recover agad si Clowie para hindi na lumala ang sakit nya as verbalized by the mother. III. History A. Medical History of Past Health a. Pediatric/Childhood/ Adult Illness: Cough and Colds__________ b. Injuries or Accidents: none____________________ c. Hospitalizations and Operations: none____________________ d. Obstetric History (for female clients only): _________N/A__________ e. Immunizations: BCG: ( ) at birth ( ) school entrants DPT: ( ) 1st dose ( ) 2nd dose ( ) 3rd dose st nd OPV: ( ) 1 dose ( ) 2 dose ( ) 3rd dose HEPA B:( ) 1st dose ( ) 2nd dose ( ) 3rd dose TH AMV: ( ) 9 month TT: ( ) 1st dose ( ) 2nd dose ( ) 3rd dose ( )4TH dose ( )5th dose Others: ( )Varicella Vaccine ( ) Influenza Vaccine ( ) Others, specify ______________________ f. Allergies ( ) Food, specify: ______none________________________ ( ) Drugs, specify: __________none___________________ ( ) Chemicals, specify; ___________none_______________ ( ) Environmental allergies, specify: ____none___________

II.

B. Family History (through Genogram/Family tree, with brief explanation of significant data)

IV.

Functional Assessment (narrative presentation) A. Health perception/health management pattern (describes client s perceived patterns of health and well-being and how his health is managed) The mother described the patient being active and playful when the patient is not sick. She also added that she is giving her daughter vitamins (such as tiki-tiki) in belief that this will help reinforce the patient s immunity against diseases. Whenever her daughter is acting a little strange, she observes her for any signs of illness. They are also having a regular check-up to the clinic. The mother also did a research regarding her daughter s current illness in order to fully understand the diagnosis. B. Self esteem, self concept, self perception pattern (describes how person s perceive themselves, their capabilities, body image and feelings) Not applicable due to age of the client C. Activity-exercise pattern (describes pattern of exercise, activity, leisure and recreation, includes activities of daily living, type and quality of exercise and factors affecting activity pattern) Prior to admission, mother verbalized that the patient is playful, happy and active all the time. She plays with her cousin and her favourite toys, she likes to crawl around and is not easily tired. However, since her admission to the hospital, patient is noticeably weak looking, always asleep and is very irritable. She only resumes playing with her toys 3 days after admission. No reports of problems on general mobility.

D. Nutritional-metabolic pattern (describes consumption relative to metabolic need and nutrient supply, includes pattern of food and fluid consumption, condition of skin, hair, nails and mucous membrane, body temperature, height and weight) Magana naman siya kumain, more on water as verbalized by the mother. The patient has no diet restrictions and is more frequent on fluid intake such as water and milk. Good appetite. Prefers sweets and dislikes vegetables. No change in weight since admission. Mother also gives vitamin supplements such as Tiki-tiki and Celin. 24 hour food recall consists of porridge, milk and water. E. Elimination pattern (describes patterns of excretory function, bowel, bladder and skin; includes individual s daily pattern, changes and disturbances) Urine is clear and concentrated; consumes approximately 6-7 diapers a day. Stool is yellowish in consistency and well formed. Defecates 2-3 times a day. No significant change with regards to urination since admitted to hospital. Regular defecation only started 3 days after admission. F. Sleep rest pattern (describe pattern of sleep, rest and relaxation) Sleeps around 8pm-9pm; intermittent sleep and wakes up in the middle of the night usually around 3am, seeking comfort or milk and goes back to sleep. No other reported problem on sleep. Wakes up around 8am-9am. Nap time after lunch. However, patient spends more time asleep ever since her hospitalization; very restless when awake and easily awakes when touched. G. Cognitive- perceptual pattern (describes sensory-perceptual and cognitive patterns, includes adequacy of sensory modes; vision, hearing, touch, taste and smell: reports of pain perception and cognitive functional abilities)

madaling maka catch-up si Clowie (patient), pag tinuturaan mo naalala nya yung mga simple things as verbalized by the mother. However, since her hospitalization, the patient s pain threshold seemed to have been much lower than before she was admitted. parang na trauma na sya sa mga hospital workers, kasi lagi syang kinukunan ng CBC so parang sensitive sya lalo sa pain . No reports on sensory deficits and other problems. H. Role relationship pattern (describes pattern of role engagements and relationships; includes perception of major roles and responsibilities in current life situation) The patient is more close to her mother than her father. medyo mailap sya sa tao, lalo na pag hindi nya kilala said her mother. The patient also likes to play with her cousins, but most of the time she is alone, since she is the only child. I. Sexuality Reproductive pattern (describe patterns of satisfaction or dissatisfaction with sexuality; includes female reproductive state) Not applicable due to client s age. J. Coping-stress tolerance pattern )describes general coping pattern and effectiveness of coping skills in stress tolerance) The patient is reported of having separation anxiety when being left to the caregiver when their parents go to work. She constantly cries but eventually stops when she sees her favourite cartoon shows or when being played with. Since her hospitalization, she became more guarding and restless whenever she sees a health care worker like nurses. K. Value belief pattern (describes patterns of value, goals or beliefs that guide lifestyle choices and decisions) The patient is catholic. No other data is provided due to client s age.

Physical Examination PARTS A. Vital Signs (latest) WHAT TO ASSESS y y y y B. Integumentary 1. Skin Temperature Pulse Respiration Blood Pressure ACTUAL FINDINGS 36.3 c 145bpm 43cpm 80/60 mmHg CLINICAL SIGNIFICANCE Normal Normal Normal Normal

Color, odor, temperature, moisture, texture, thickness, mobility, turgor, vascularity, swelling, rashes

Light brown in color, generally uniform in color except for the presence of bruise on the Lest deltoid area. No edema, well hydrated and moisturized. No rashes or swelling.

Hematoma on Left deltoid area. 3-4in. In diameter, purple-black in color. Warm to touch.

2. Hair

Distribution, thickness, texture, lubrication, scalp characteristics

Well moisturized scalp, no presence of parasites, and no tenderness. Hair equally distributed, black in color.

Normal

3. Nails

Nail bed color, consistency, thickness, shape, texture, angle between nail and nail bed, capilliary refill

Smooth in texture, pinkish in color. Intact epidermis except for the puncture site for CBC. Prompt capillary return of pink

Normal

C. Head and Neck 1. Head

y y

Size, shape, contour For infants, anterior and posterior fontanels for shape, size, texture, closure Visual acuity, extra ocular movement, visual fields, position and alignement Eyebrows: symmetry, movement, extension, quantity of hair Eyelashes: symmetry, movement, extension, quantity of hair Eyelids: position and mov t, color Conjuctive: color Pupils: equality, shape, reaction to light and accommodation

Normocephalic, smooth skull Normal contours, anterior fontanels about 1-2cm in size.

2. Eyes

No opportunity for assessment of visual aquity due to age of client

Hair evenly distributed, thin. Symmetrically aligned

Normal

Equally distributed, curled slightly outward

Normal

y y y

Skin intact, no discharge, no discoloration, lids close symmetrically PERRLA

Normal

Normal

3. Ears

Auricle: position, size, shape, texture External auditory canal: discharge, cerumen s color, consistency Hearing acuity

Fairly uniform in color, symmetrical and aligned, no tenderness Dry cerumen, skin intact and no tenderness

Normal

Normal

Turns and responds to verbal stimulation Normal

4. Nose

y y y y

External nose: shape, symmetry, texture, skin color Nares: shape, symmetry, discharge Mucosa: color, discharge Septum: symmetry Sinus: texture Lips: color, texture, hydration, contour

Symmetric, uniform in color, no tenderness. Presence of small scratches.

There are scabs around the nose and cheek area.

Symmetrical

Normal

Pinkish in color, clear watery discharge Nasal septum intact ad in middle. Not tender

Normal

Normal

Normal

5. Mouth

y y

y y y

Teeth: position, color, hygiene Tongue: color, position, texture, coating, mobility Gums: color, texture Pharynx: color, hydration Flow of saliva

Tooth development appropriate to age. Lips pink in color, symmetrical, no lesions, and tenderness, soft moist and smooth. Tongue pinkish in color, moves freely with no tenderness and smooth. Mouth well hydrated and moisturized, drooling.

Normal

6. Neck

y y y

Mobility Thyroid gland; movement, size Lymph nodes; number, size, location, consistency Vein: fillings, pulsation

Head centered, slightly palpable lymph nodes. Neck size appropriate to age.

Normal

D. Thorax and Lungs y y y y Shape, symmetry Chest excursion or movement RR and rhythm Position of spine, slope of ribs, symmetry of scapula costal angle Tactile fremitus or lung vibration Use of accessory muscle for breathing Chest is symmetric. Spine is vertically aligned. Skin intact and uniform in temperature and color. No tenderness or swelling. Abdominal breathing. Quite, rhythmic and effortless respirations. Normal

y y

E. Breast and Axillas y Size, symmetry, skin color, contour, shape Venous pattern Moles and other markings Areola: size, shape, surface characteristics Nipples: size, shape, color, direction, surface characteristics, discharge Lymph node on each axilla: location, number, size, mobility Chest color fairly uniform. Skin is smooth and intact. No discharge. No palpable nodes. Normal

y y y

F. Heart y y Appearance of pulsation Apical pulse or PMI: location, strength and synchrony with no visible pulsations. Symmetric pulse volumes. Limbs not tender. Skin color pink, skin temperature is not excessively warm or cold. No edema, skin texture resilient

y y

carotid pulse Abdominal aorta strength Heart sounds: rhythm, rate, loudness

and moist.

Regular heart sounds

G. Abdomen y y y y Contour, symmetry Bowel sounds Percussion notes Surface characteristics, distention Umbilicus: position, shape, color Normal respiratory movement Symmetrical contours, uniform skin color, no blemishes or tenderness. Protruding abdomen. No visible peristaltic movements. No palpable masses Normal

H. Genitourinary y Female: color, pubic hair, characteristics of mons pubis, labia, clitoris, vestibule, perineum Male: position of scrotum, penis opening, veins Anus and perineal tissue Not applicable

I.

Muskoskeletal y y y Gait, stance, posture Backbone Extremities, alignment, position Muscle strength Muscle size equal on both sides. No contractures, no tremors. Normally firm muscle tone. No deformities, tenderness or swelling. Genu Varum (knock-knee) Normal

y y

Range of motion of joints Muscle coordination

Equal strength on both side Full range of motion during activities Smooth coordinated movements. Conscious, coherent and responds to verpal and pain stimulation Normal

J.

Neurologic y Level of consciousness: language, response to stimulation, intellectual function, abstract thinking, ability to perform simple arithmetic calculations, make judgement

Significant Signs and Symptoms Typical cases of Dengue Hemorrhagic Fever (DHF) are characterized by four major clinical manifestations: 1. High fever 2. Haemorrhagic phenomena 3. Hepatomegaly 4. Circulatory failure Moderate to marked thrombocytopenia with concurrent haemoconcentration is a distinctive clinical laboratory finding in DHF. The major pathophysiological change that determines the severity of disease in DHF- and differentiates it from Dengue Fever (DF)- is the leake of plasma, as manifested by an elevated hematocrit, a serous effusion or hypoproteinaemia. Children with DHF commonly present with a sudden rise in temperature accompanied by facial flush and other non-specific constitutional symptoms resembling DF, such as anorexia, vomiting, headache and muscle or bone and joint pain. Some patients complain of sore throat, and an injected pharynx is frequently evident on examination, but rhinitis and cough are infrequent. Mild conjuctival injection may be observed. Epigastric discomfort, tenderness at the right costal margin, and generalized abdominal pain are common. The temperature is usually high (>39 c) and remains so for 2-7 days. Occasionally, temperature may be as high as 40-41 c; febrile convulsions may occur, particularly in infants. The most common hemorrhagic phenomenon is a positive tourniquet test, easy bruising and bledding at venepuncture sites. Present in most cases are easy bruising and bleeding at venepuncture sites. Present in most cases are discrete fine petichiae scattered on the extremities, axillae, face and soft palate, which are usually seen during the early febrile phase. Epistaxis and gingival bleeding occur infrequently; mild gastrointestinal haemorrhage may be observed during febrile period.

The liver is usually palpable early in the febrile phase and varies in size from just palpable to 2-4 cm below costal margin. Although liver size is not correlated with the disease severity, an enlarged liver is observed more frequently in shock than in non-shock cases. The liver is tender, but jaundice is not usually observed. Splenomegaly is rarely observed in infants; however, the spleen may be prominent on x-ray examination. The critical stage of the disease course is reached at the end of the febrile phase. After 207 days of fever, a rapid fall in temperature is often accompanied by signs of circulatory disturbance of varying severity. The patient may sweat, be restless, have cool extremities and show changes in pulse rate and blood pressure. In less severe cases, these changes are minimal and transient, reflecting a mild degree of plasma leakage. Many patients recover spontaneously, or after a short period of fluid and electrolyte therapy. In more severe cases, when plasma loss is critical, shock ensues and can progress rapidly to profound shock and death if not properly treated. The severity of the disease can be modified by early diagnosi and replacement of plasma loss. Thrombocytopenia and haemoconcentration are usully detectable before the subsidence of fever and the onset of shock. Clinical Findings

y y

Fever, history of acute fever (40 c), lasting 3-5 days, occasional biphasic. Heamorrhagic tendencies, evidenced by: o o o o A positive tourniquet test Petechiae, ecchymoses or purpura Bleeding from the mucosa, gastrointestinal tract, injection sites or other locations Heamatemesis or melaena

Thrombocytopenia (100,000 cells per mm3 or less)

Evidence of plasma leakage due to increased vascular permeability, manifested by: o A rise in the hematocrit equal to or greater than 20% above average for age, sex and population o A drop in the hematocrit following volume-replacement treatment equal to or greater than 20% of baseline o Signs of plasma leakage such as pleural effusion, ascites and hypoproteinaemia.

Grading Severity of DHF Grade I: Fever accompanied by non-specific constitutional symptoms; the only haemorrhagic manifestation is a positive tourniquet test and /or easy bruising Grade II: Spontaneous bleeding in addition to the manifestation of grade II patients, usually in the forms of skin or other haemorrhages Grade III: Circulatory failure manifested by a rapid pulse and narrowing of pulse pressure or hypotension, with the presence of cold, clammy skin and restlessness Grade IV: profound shock with undetectable blood or pulse

Pathophysiology Predisposing Geographical area tropical islands in the Pacific (Philippines) and Asia Precipitating Environmental conditions (open spaces with water pots, and plants) Immuno compromise Mosquito carrying dengue virus Soldier Sweaty skin

Aedes aegypti (dengue virus carrier): 8-12 days of viral replication on mosquito s salivary glands

Bite from mosquito (Portal of Entry in the skin) Allowing dengue virus to be inoculated towards the circulation/blood (Incubation Period: 3-14 days) Redness & itchiness in the area

Cellular direct destruction and infection of red bone marrow precursor cells as well as immunological shortened platelet survival causing platelet lyses

Virus ultimately targets liver and spleen parenchymal cells where infection produces apoptosis/cell death

Virus disseminated rapidly into the blood and stimulates WBCs including B lymphocytes that produces and secretes immunoglobulins (antibodies), and monoctes/mocrohes, neutrohils

Antibodies attach to the viral antigens, and then monocytes/macrophages will perform phagocytosis through Fc receptor (FcR) within the cells and dengue virus replicates in the cells Recognition of dengue viral antigen on infected monocyte by cytotoxic T cells Release of cytokines which consist of vasoactive agents such as interleukins, tumor necrosis factor, urokinase and platelet activating factors which stimulates WBCs and pyrogen release

Hepatosplenomegaly

Thrombocytopenia

atos
Dengue Fever

Dengue Hemorrhagic Fever

Anatomy and Physiology Lymphatic and Immune Systems A number of mechanisms operate within the bodies of birds and mammals that either prevent infection or fight infection by foreign particles and cells. Nonspecific immunity refers to mechanisms that are generally effective against a variety of infections. Specific immunity refers to mechanisms that are specific for one type of infection. Specific immunity is generally acquired after exposure to the infecting particles or cells. Barriers to Entry: The skin is the main barrier preventing the entry of foreign organisms and particles. Skin oils weaken or kill bacteria. Cilia lining the respiratory tract sweep mucus and trapped particles to the throat where they are swallowed. The low pH of the stomach kills microorganisms. Tears wash the eyes. Saliva helps clean teeth, preventing dental caries. Urine flow prevents colonization of the urinary tract. Vaginal secretions move microorganisms out of the reproductive tract. The normal bacterial colonists of the skin, gut, and vagina prevent harmful microorganisms from colonizing the areas.

Inflammatory Reaction The inflammatory reaction is a local response to injury. Damaged tissue releases bradykinin, which causes pain and stimulates mast cells to release histamine. Bradykinin and histamine produce vasodilation, ( increased blood vessel diameter) to increase blood flow to the area.

Bradykinin and histamine also cause increased permeability (allows fluid to leak out). This brings more defensive cells and chemicals to the area. Neutrophils and monocytes are amoeboid white blood cells (leukocytes) that squeeze out of the capillaries and enter the damaged tissue. Neutrophils phagocytize foreign material. Monocytes are transformed into macrophages, which can phagocytize a large number of viruses and bacteria. Macrophages release white blood cell growth factor. This hormone stimulates the bone marrow to produce leukocytes (white blood cells). Pus is a large # of dead leukocytes that fought infection. Antibody-Mediated Immunity

Antigens and Antibodies Antibodies are proteins that protect against foreign invaders, either foreign molecules, viruses, or cells. They are capable of recognizing specific particles due to their shape. Their ability to recognize foreign shapes makes them useful in defending against foreign invaders. Antigens are molecules that antibodies are capable of being recognized. They are usually a protein or carbohydrate chain. The body can recognize bacteria and viruses as being foreign because they have antigens on their surface which are different than the bodies "self" antigens.

Antibodies are Y-shaped molecules with a constant region and two binding sites that vary from one antibody to the next. Antibodies fit together with and bind with antigens like a lock and key. The body does not produce antibodies that bind to its own (self) antigens. Therefore all particles that are bound to antibodies are foreign. Cells, particles, or molecules that are marked with antibodies: 1. may be phagocytized (engulfed) by neutrophils or macrophages. 2. may agglutinate (clump together) because each antibody is capable of binding to two antigens. If the antigens are chemicals that are dissolved in the body fluids, the clumps of

antibody-bound particles will precipitate. Antigens attached to cells will cause the cells to clump together. The clumps are then phagocytized. 3. may activate the complement system (discussed below). The complement system is a system of blood proteins that enhances the elimination of foreign cells or particles. During our life, we will encounter over 1 million different antigens, so we need at least 1 million different antibodies, one for each kind of antigen. There are 5 different classes of antibodies (IgA, IgD, IgG, IgH, IgM). One class contains pentamers, another contains dimers. Antibodies are produced by B lymphocytes.

B Lymphocytes B lymphocytes (B cells) mature in the bone marrow. B lymphocytes have receptors (antibodies) attached to their surface which function to detect antigens. There is only one specific kind of receptor on the surface of a lymphocyte. A single B lymphocyte can therefore detect only one kind of antigen. Our bodies have millions of different kinds of B lymphocytes.

Clonal selection B cells that encounter the correct antigen with their antibody receptors become activated and begin to divide many times producing plasma cells, which, in turn produce antibodies.

B lymphocyte + antigen p more B-cells (called memory B-cells) and plasma cells p antibodies B lymphocyte + incorrect antigen p no reaction Plasma cells produce antibodies that are identical to the receptors on the surface of the B cell that was initially stimulated by antigen. The antibodies therefore can adhere to the type of invader that initially activated the B cell. Memory B cells are B cells that are produced as a result of stimulation by the antigen. Because there are now many of these to fight off future infection, they are called memory B cells. Large numbers of B-cells are found in the lymph nodes and in the spleen. The Complement System The complement system consists of a number of different proteins that help defend the body when they are activated. Each activated complement protein activates many others so that a large number of active proteins are produced. The following may initially activate the complement system: Antigen-Antibody interaction Substances on the capsules or cell walls of microorganisms; microorganisms substances produced by

Functions of the Complement System: The activated proteins stimulate mast cells causing inflammation and attract phagocytes (neutrophils, macrophages) to the area. Complement proteins bind to microorganisms and other particles enhancing their recognition by phagocytes. Other complement proteins produce holes in bacterial cell walls allowing salts and fluids to enter, rupturing the cell. It is called complement because it enhances (complements) other immune responses such as the inflammatory reaction and the antibody-mediated response (the proteins bind to microbes that already have antibodies attached, improving recognition by phagocytes). Some Important Molecules Interferons Interferons are proteins produced by virus-infected animal cells that stimulate other cells to produce substances that interfere with viral replication. Lysozyme Lysozyme is an enzyme capable of breaking down the cell walls of gram-positive bacteria. It is found in perspiration, tears, saliva, nasal secretions, and tissue fluids. Cell-Mediated Immunity T lymphocytes (T-cells) are lymphocytes that mature in the thymus.

This type of immunity is used to fight cells such as cancer cells, virus-infected cells, single-celled fungi, parasites, and cells of an organ transplant. T Lymphocytes Activating T Cells T cells cannot recognize antigens unless an antigen-presenting cell (usually a macrophage) presents the antigens to them. The macrophage first engulfs the antigen (or bacterium, virus, etc.) and brings fragments of the foreign antigens to its surface linked to its own (self) antigens. The "self" antigen is referred to as an "MHC" protein. (MHC = major histocompatibility complex) If receptors on a virgin T cell match both the self and foreign antigens, the T cell becomes activated and undergoes clonal expansion (cell reproduction) producing the 4 kinds of T cells described below. Cytotoxic T Cells Cytotoxic T cells (also called killer T cells) attack antigen-MHC bearing cells. Because MHC is a "self" marker and antigens are part of foreign particles, Cytotoxic T cells attack the body s own cells that are infected viruses and microorganisms. They also attack cancer cells because they have mutated (therefore foreign) antigens. The cytotoxic T cell releases proteins that penetrate the target cell membrane. Salts and fluid enter through the holes and the cell ruptures.

Helper T Cells When exposed to an antigen-MHC complex, Helper T cells secrete lymphokines, which enhance the response of other immune cells. For example, they stimulate T cells to clone, macrophages to phagocytize, and B cells to become plasma cells and produce antibodies. HIV (the virus that causes AIDS) attacks helper T cells as well as others in the immune system. HIV therefore prevents the immune system from becoming activated.

Suppressor T Cells Suppressor T cells regulate the immune response by suppressing the activity and development of B cells and helper T cells. They do this by secreting inhibitory chemicals in response to declining antigen levels. Memory T Cells Memory T cells are T cells that persist after infection. They will secrete lymphokines if the same antigen reenters the body.

Active and Passive Immunity Active immunity is produced in individuals by administering foreign antigens. These antigens may come from weakened or dead microorganisms. This process is called vaccination. Genetically engineered bacteria are currently being used to produce some antigens. Examples: malaria, hepatitis B. After exposure to antigens in a vaccine, the level of antibodies in the blood begins to increase after several days, levels off, then declines. After a secondary exposure (called a booster), the level increases rapidly. Memory B cells and memory T cells allow the individual to be actively immune. If they are exposed to the disease, a rapid immune response will occur because they already have large numbers of the correct B and T cells. Passive immunity occurs when an individual receives antibodies instead of making their own. Passive immunity is short-lived because the person s B and T cells have not been stimulated to produce antibodies. The immunity lasts only as long as the antibodies they received remain in their bloodstream. Examples of Passive Immunity Newborn babies have antibodies they received from their mother. Breast-fed babies receive antibodies from their mother s milk.

Allergies Allergies are due to an overactive immune system. Mast cells contain antibody receptors to allergens (antigens) and when stimulated, they secrete histamine. Histamine causes mucus secretion, airway constriction, and inflammation due to blood vessels leaking. Leaky blood vessels cause the tissues to swell. Allergy shots stimulate the body to produce high levels of antibodies. The antibodies react with the allergens before they have a chance to interact with the mast cells. Components of the Immune System Leukocytes Leukocytes are white blood cells. The following kinds of leukocytes were discussed in this chapter: 1. neutrophils 2. monocytes (become macrophages) 3. macrophages 4. lymphocytes

B cells - mature in bone marrow T cells - mature in thymus, small intestine, skin

Lymphatic System Functions of the Lymphatic System 1. take up excess tissue fluid and return it to the bloodstream 2. absorb fats at the intestinal villi and transport to the circulatory system 3. defend against disease Lymphatic Vessels Lymphatic vessels are similar to veins, including the presence of valves. They depend on the movement of skeletal muscles to move the fluid inside. The fluid they contain is called lymph. They empty into the circulatory system via the thoracic duct and the right lymphatic duct. The thoracic duct is much larger than the right lymphatic duct. Lymph Nodes Lymph nodes are small (1-25 mm), spherical or ovoid structures that are connected to lymphatic vessels. They contain open spaces (sinuses), each with many lymphocytes and macrophages. As lymph passes through, macrophages purify it of infectious organisms and particles. The structures listed below are groups of nodules that also function to purify lymph: 1. tonsils - back of mouth 2. adenoids - back of mouth above the soft palate 3. Peyer s patches - intestinal wall

Spleen The spleen stores blood. It helps purify blood that passes through it by removing bacteria and worn-out or damaged red blood cells. Thymus Gland T lymphocytes mature in the thymus. Bone Marrow Macrophages and lymphocytes (B cells and T cells) are produced in the bone marrow. T cells mature in the thymus gland, small intestine, and in the skin. Autoimmune Diseases Autoimmune diseases result when the body is attacked by its immune system. They often appear in individuals that have recovered from other infections. Somehow the body seems to have learned to recognize itself (its own antigens). Examples: Myasthenia gravis - neuromuscular junctions are weakened Multiple sclerosis - the myelin sheath of nerve fibers is attacked Lupus erythematosus - Lupus is a chronic inflammatory disease. The skin, joints, kidneys and blood are most often affected but other organs may be affected as well. Rheumatoid arthritis - the membranes that surround the joints are attacked

Summary of Leukocytes Nonspecific response Mast cells - secrete histamine Neutrophils - participate in inflammatory response; phagocytize Monocytes - become macrophages which phagocytize; produce white blood cell growth factor Specific Immune Response

B-lymphocytes

give rise to plasma cells that produce antibodies give rise to more B lymphocytes (also called memory B lymphocytes) T-lymphocytes Cytotoxic T cells - attack cells that bear antigens Helper T cells - secrete lymphokines which enhances the response of other immune cells Suppresser T cells - suppress helper T cells and B cells Memory T cells - remain after the infection and produce the 4 kinds of T cells if activated.

Problem List/ Prioritization 1. Difficulty of Breathing 2. Potential Bleeding 3. Circulatory failure 4. Fever 5. Hygiene Nursing Diagnosis Physiological Concern Actual: 1. Hyperthermia as evidenced by elevated body temperature of 40 c

2. Ineffective tissue perfusion 3. Acute pain as evidenced by persistent crying and restlessness Potential: 1. Risk for bleeding r/t to low platelet count 2. Risk for infection Psychological Concern Actual: 1. Disturbed sleep pattern 2. Fear 3. Self care deficit Potential: 1. Caregiver role strain 2. Fatigue

Discharge Plan:

M edication Intake of appropriate vitamin supplement and diuretics to increase protection mechanism of the immune system and decreases renal vascular resistance and may increase renal blood flow, respectively. E conomic/Environment The use of nonpharmacotherapy such as drinking plenty of water will promote increase plasma in blood to increase immunity and proper hygiene and promotion of cleanliness at home and work area. T reatment Management of such condition would be through hydration and doing control measures to eliminate vector by promoting cleanliness in the environment through proper disposal of rubber tires, changing of water of lower vases once a week, destruction of breeding places of mosquito and residual spraying with insecticides. H ygiene/Health Teaching Advise to follow proper body hygiene and to maintain cleanliness on surroundings. This would prevent additional cases of DHF. O ut Patient/ Follow-up Any odd signs such as fever, petechiae, recurrence of fever,etc. must be immediately reported to the physician. D iet Instruct to increase fluid intake. Diet as tolerated by age.

References 1. Kyle JL, Harris E. Global spread and persistence of dengue. Annu Rev Microbiol. 2008;62:7192.Ross R. Atherosclerosis--an inflammatory disease. N Engl J Med. Jan 14 1999;340(2):115-26. 2. Statler J, Mammen M, Lyons A, Sun W. Sonographic findings of healthy volunteers infected with dengue virus. J Clin Ultrasound. Sep 2008;36(7):413-7. 3. Malavige GN, Fernando S, Fernando DJ, et al. Dengue viral infections. Postgrad Med J. Oct 2004;80(948):588-601. 4. Kozier, Erbs, Berman, Snyder, Fundamentals Of Nursing, Concepts, Process and Practice, 8th edition, volume 1and 2, 2008; 23-25 First Lok Yang Road, Jurong, Singapore; Pearson education, Inc., 5. Baughman D.C, hackley J.C. Brunner and Suddarts: Medical-Surgical Nursing Handbook, 1996, Lippincott-Raven Publishers, 227 East Washington, Square, Phildelphia, PA 19106. 6. Nursingcrib.com 7. Wikepedia.com 8. MedNet.com/ 30854135-dengue-hemorrhagic-fever