DENGUE FEVER

Key Facts
● Dengue is a viral infection transmitted to humans through the bite of infected mosquitoes. The primary
vectors that transmit the disease are Aedes aegypti mosquitoes and, to a lesser extent, Ae. albopictus.
● The virus responsible for causing dengue is called the dengue virus (DENV). There are four DENV
serotypes and it is possible to be infected four times.
● Severe dengue is a leading cause of serious illness and death in some Asian and Latin American countries.
It requires management by medical professionals.
● There is no specific treatment for dengue/severe dengue. Early detection of disease progression associated
with severe dengue, and access to proper medical care lowers fatality rates of severe dengue to below 1%.
● Dengue is found in tropical and sub-tropical climates worldwide, mostly in urban and semi-urban areas.
● The global incidence of dengue has grown dramatically with about half of the world's population now at
risk. Although an estimated 100-400 million infections occur each year, over 80% are generally mild and
asymptomatic.
● Dengue prevention and control depends on effective vector control measures. Sustained community
involvement can improve vector control efforts substantially.
● While many DENV infections produce only mild illness, DENV can cause an acute flu-like illness.
Occasionally this develops into a potentially lethal complication, called severe dengue.

Dengue is a mosquito-borne viral disease that has rapidly spread to all regions of WHO in recent years. Dengue
virus is transmitted by female mosquitoes mainly of the species Aedes aegypti and, to a lesser extent, Ae. albopictus.
These mosquitoes are also vectors of chikungunya, yellow fever and Zika viruses. Dengue is widespread throughout
the tropics, with local variations in risk influenced by climate parameters as well as social and environmental
factors.

Dengue causes a wide spectrum of diseases. This can range from subclinical disease (people may not know they are
even infected) to severe flu-like symptoms in those infected. Although less common, some people develop severe
dengue, which can be any number of complications associated with severe bleeding, organ impairment, and/or
plasma leakage. Severe dengue has a higher risk of death when not managed appropriately. 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
and adults in these regions.

Dengue is caused by a virus of the Flaviviridae family and there are four distinct, but closely related, serotypes of
the virus that cause dengue (DENV-1, DENV-2, DENV-3, and DENV-4). Recovery from infection is believed to
provide lifelong immunity against that serotype. However, cross-immunity to the other serotypes after recovery is
only partial and temporary. Subsequent infections (secondary infection) by other serotypes increase the risk of
developing severe dengue.

Dengue has distinct epidemiological patterns, associated with the four serotypes of the virus. These can co-circulate
within a region, and indeed many countries are hyper-endemic for all four serotypes. Dengue has an alarming impact
on both human health and the global and national economies. DENV is frequently transported from one place to
another by infected travelers; when susceptible vectors are present in these new areas, there is the potential for local
transmission to be established.

PREDISPOSING FACTORS
● Age (?)
● Sex (?)
● Race (?)
 ● Nutrition (?)
● Living in endemic areas ( Dengue Belt)
○ Caribbean (including Puerto Rico)
○ Central and South America
○ Southeast Asia
○ Pacific Islands
● Secondary Infection (?)

PRECIPITATING FACTORS
● Poor sanitation
● Recent travel to endemic areas
● Availability of mosquito breeding sites
● Exposure to infected mosquito

DIAGNOSTIC TESTS
● Currently, several diagnostic tools are being implemented for clinical, molecular, and immunological
diagnosis. The most common diagnostic tools are:
○ PCR and dengue nonstructural protein 1 (NS1) which detect the antigen, and;
○ serological IgM and Immunoglobulin G (IgG) tests, which detect antibodies.
○ CBC with platelet

ETIOLOGY
➔ Dengue infection is caused by dengue virus (DENV), which is a single-stranded RNA virus (approximately
11 kilobases long) with an icosahedral nucleocapsid and covered by a lipid envelope. The virus is in the
family Flaviviridae, genus Flavivirus, and the type-specific virus is yellow fever.
➔ Transmission of the dengue virus into the host is through the vectors.
➔ Dengue is transmitted by an infected female mosquito.
➔ A.aegypti is primarily a daytime feeder. It lives around human habitation.
➔ Lays eggs and produces larvae preferentially in artificial containers. Only the female Aedes mosquito bites
as it needs the protein in blood to develop its eggs.
➔ The mosquito becomes infective approximately 7 days after it has bitten a person carrying the virus.
➔ This is the extrinsic incubation period, during which time the virus replicates in the mosquito and reaches
the salivary glands.
➔ The mosquito remains infected for the remainder of its life. The life span of A. aegypti is usually 21 days
but ranges from 15 to 65 days.
➔ The mosquito can lay eggs about 3 times in its lifetime, and about 100 eggs are produced each time.
➔ The eggs can lie dormant in dry conditions for up to about 9 months, after which they can hatch if exposed
to favorable conditions, i.e. water and food.
➔ Etiologic Agent: Dengue Virus Types 1, 2, 3, & 4 and Chikungunya virus
PATHOGENESIS

SIGNS AND SYMPTOMS

● Mild symptoms of dengue can be confused with other illnesses that cause fever, aches and pains, or a rash.
The most common symptom of dengue is fever with any of the following:
● Nausea, vomiting
● Rash
 ● Aches and pains (eye pain, typically behind the eyes, muscle, joint, or bone pain)
● Any warning sign
Symptoms of dengue typically last 2–7 days. Most people will recover after about a week.

An acute febrile infection of sudden onset with clinical manifestation of 3 stages:

● First 4 days - Febrile or invasive stage starts abruptly as high fever, abdominal pain and headache; later
flushing which may be accompanied by vomiting, conjunctival infection and epistaxis.
● 4th-7th days- Toxic or hemorrhagic stage- lowering of temperature, severe abdominal pain, vomiting and
frequent bleeding from the gastrointestinal tract in the form of hematemesis or melena. Unstable B. P.,
narrow pulse pressure and shock. Death may occur. Tourniquet test which may be positive on 3rd day may
become negative due to low or vasomotor collapse.
● 7th-10th day - convalescent or recovery stage generalized flushing with interventing areas of blanching
appetite regained and blood pressure already stable.

IF TREATED
MEDICAL MANAGEMENT
The management of DHF is actually simple as long as it is detected early.
● Oral rehydration therapy. Oral rehydration therapy is recommended for patients with moderate
dehydration caused by high fever and vomiting.
● IV fluids. IVF administration is indicated for patients with dehydration.
● Blood transfusion and blood products. Patients with internal or gastrointestinal bleeding may require
transfusion, and patients with coagulopathy may require fresh frozen plasma.
● Oral fluids. Increase in oral fluids is also helpful.
 ● Avoid aspirins. Aspirin can thin the blood. Warn patients to avoid aspirins and other NSAIDs as they
increase the risk of hemorrhage.

PHARMACOLOGICAL MANAGEMENT
No treatment: No specific antiviral agents exist for dengue. Supportive care is advised: Patients should be advised to
stay well hydrated and to avoid aspirin (acetylsalicylic acid), aspirin-containing drugs, and other nonsteroidal
anti-inflammatory drugs (such as ibuprofen) because of their anticoagulant properties.

SURGICAL MANAGEMENT
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NURSING CARE MANAGEMENT

Nursing management of patients with DHF is essential in achieving complete recovery.

Nursing Assessment
Assessment of a patient with DHF should include:
● Evaluation of the patient’s heart rate, temperature, and blood pressure.
● Evaluation of capillary refill, skin color and pulse pressure.
● Assessment of evidence of bleeding in the skin and other sites.
● Assessment of increased capillary permeability.
● Measurement and assessment of the urine output.

NCP - Nursing Diagnosis and Interventions

Risk for bleeding related to possible impaired liver function

INTERVENTIONS RATIONALES

Educate the at-risk patient about precautionary Information about precautionary measures lessens the
measures to prevent tissue trauma or disruption of the risk for bleeding.
normal clotting mechanisms.
1. Use a soft-bristled toothbrush and nonabrasive 1. This method providing oral hygiene reduces
toothpaste. Avoid the use of toothpicks and trauma to oral mucous membranes and the risk
dental floss. for bleeding from the gums.
2. Avoid rectal suppositories, thermometers, 2. These invasive devices or medications may
enemas, vaginal douches, and tampons. cause trauma to the mucous membranes that
3. Limit straining with bowel movements, line the rectum or vagina.
forceful nose blowing, coughing, or sneezing. 3. These activities may cause trauma to the
4. Be careful when using sharp objects like mucosal linings in the rectum, nasal passages,
scissors and knives. Use an electric razor for or upper airways.
shaving (not razor blades). 4. The patient needs to avoid situations that may
cause tissue trauma and increase the risk for
bleeding.

Educate the patient and family members about signs of Early evaluation and treatment of bleeding by a health
bleeding that need to be reported to a health care care provider reduce the risk for complications from
provider. blood loss.

Inform the patient to check the color and consistency of Bright red blood in the stools is an indicator of lower
stools. gastrointestinal bleeding. Stool that has a dark
greenish-black color and a tarry consistency is linked
 with upper gastrointestinal bleeding.

Tell the patient to observe skin and mucous membranes Oozing of blood is often an early sign of coagulation
for oozing of blood. abnormalities that increase the risk of bleeding.

Tell the family members to be active in Tell the family members to be active in
decision-making about the treatment of the patient at decision-making about the treatment of the patient at
risk for bleeding. risk for bleeding.

Deficient fluid volume related to vascular leakage

INTERVENTIONS RATIONALES

Urge the patient to drink the prescribed amount of Oral fluid replacement is indicated for mild fluid deficit
fluid. and is a cost-effective method for replacement
treatment. Older patients have a decreased sense of
thirst and may need ongoing reminders to drink. Being
creative in selecting fluid sources (e.g., flavored
gelatin, frozen juice bars, sports drink) can facilitate
fluid replacement. Oral hydrating solutions (e.g.,
Rehydralyte) can be considered as needed.

Emphasize the importance of oral hygiene. A fluid deficit can cause a dry, sticky mouth. Attention
to mouth care promotes interest in drinking and reduces
the discomfort of dry mucous membranes.

Insert an IV catheter to have IV access. Parenteral fluid replacement is indicated to prevent or

treat hypovolemic complications.

Administer parenteral fluids as prescribed. Consider the Fluids are necessary to maintain hydration status.
need for an IV fluid challenge with an immediate Determination of the type and amount of fluid to be
infusion of fluids for patients with abnormal vital signs. replaced and infusion rates will vary depending on
clinical status.

Teach family members how to monitor output. Instruct An accurate measure of fluid intake and output is an
them to monitor both intake and output. important indicator of a patient’s fluid status.

Pain related to abdominal pain and severe headaches

INTERVENTIONS RATIONALES

Provide measures to relieve pain before it becomes It is preferable to provide an analgesic before the onset
severe. of pain or before it becomes severe when a larger dose
may be required.

Provide nonpharmacologic pain management. Nonpharmacologic methods in pain management may

include physical, cognitive-behavioral strategies, and
lifestyle pain management.

Perform nursing care during the peak effect of Oral analgesics typically peak in 60 minutes, and
analgesics. intravenous analgesics in 20 minutes. Performing
nursing tasks during the peak effect of analgesics
optimizes client comfort and compliance in care.

Administer analgesia before painful procedures Doing so will help prevent pain caused by relatively
 whenever possible. painful procedures (e.g., wound care, venipunctures,
chest tube removal, endotracheal suctioning, etc.).

Evaluate the effectiveness of analgesics as ordered and The patient’s effectiveness of pain medications must be
observe for any signs and symptoms of side effects. evaluated individually since they are absorbed and
metabolized differently.

Risk for ineffective tissue perfusion related to failure of the circulatory system
INTERVENTIONS RATIONALES

Check for optimal fluid balance. Administer IV fluids Sufficient fluid intake maintains adequate filling
as ordered. pressures and optimizes cardiac output needed for
tissue perfusion.

Note urine output. Reduce renal perfusion may take place due to vascular
occlusion.

Administer medications as prescribed to treat These medications facilitate perfusion for most causes
underlying problem. Note the response. of impairment.
1. Antiplatelets/anticoagulants 1. These reduce blood viscosity and coagulation.
2. Peripheral vasodilators 2. These enhance arterial dilation and improve
3. Antihypertensives peripheral blood flow.
4. Inotropes 3. These reduce systemic vascular resistance and
optimize cardiac output and perfusion.
4. These improve cardiac output.

Provide knowledge on normal tissue perfusion and Knowledge of causative factors provides a rationale for
possible causes of impairment. treatments

Teach patient to recognize the signs and symptoms that Early assessment facilitates immediate treatment.
need to be reported to the nurse.

NURSING CARE (from Public Health Nursing in the Philippines BOOK)

Any disease or condition associated with hemorrhage is enough cause for alarm. Immediate control of hemorrhage
and close observation of the patient for vital signs leading to shock are the nurse's primary concern. Nursing
measures are directed towards the symptoms as they occur but immediate medical attention must be sought:
1. For hemorrhage - keep the patient at rest during bleeding episodes. For nose bleeding, maintain an
elevated position of trunk and promote vasoconstriction in nasal mucosa membrane through an ice bag over
the forehead. For melena, ice bag over the abdomen. Avoid unnecessary movement. If transfusion is given,
support the patient during the therapy. Observe signs of deterioration (shock) such as low pulse, cold
clammy perspiration, prostration.
2. For shock - Prevention is the best treatment. Dorsal recumbent position facilitates circulation.
● Adequate preparation of the patient, mentally and physically prevents occurrence of shock.
● Provision of warmth-through lightweight covers (overheating causes vasodilation which
aggravates bleeding).
3. Diet - low fat, low fiber, non-irritating, non-carbonated. Noodle soup may be given.
MANAGEMENT (from Public Health Nursing in the Philippines BOOK)
Supportive and symptomatic treatment should be provided
● For fever, give paracetamol for muscle pains. For headaches, give analgesics. DON'T give ASPIRIN.
● Rapid replacement of body fluids is the most important treatment
● Includes intensive monitoring and follow-up
● Give CRESOL to replace fluid as in moderate dehydration at 75 ml/kg in 4-6 hours or up to 2-3L in adults.
Continue ORS intake until the patient's condition improves.

METHODS OF PREVENTION AND CONTROL (from Public Health Nursing in the Philippines BOOK)
The infected individual, contacts and environment:
● Recognition of the disease.
● Isolation of patient (screening or sleeping under the mosquito net)
● Epidemiological investigation
● Case finding and reporting
● Health Education

INCUBATION PERIOD: 5-7 days

IF NOT TREATED
COMPLICATIONS
● If dengue hemorrhagic fever is not treated right away, a person can have heavy bleeding and a drop in
blood pressure, and could even die. People with dengue hemorrhagic fever need to be treated in a medical
facility immediately.

GOOD PROGNOSIS POOR PROGNOSIS

Dengue fever is typically a self-limited disease with a The causes of mortality in dengue infection are from
mortality rate of less than 1% when detected early and prolonged shock, massive bleeding and fluid
with access to proper medical care. When treated, overload. The main problem leading to poor prognosis
severe dengue has a mortality rate of 2%-5%, but, or death is not being diagnosed when presenting in
when left untreated, the mortality rate is as high as critical conditions at the hospitals.
20%.