Polytechnic College of Davao del Sur, Inc.

McArthur Highway, Brgy. Kiagot, 8002 Digos City, Davao del Sur, Philippines

In Partial Fulfilment of the Requirements in RLE 104

RLE
A Case Study

Presented to:

BSN II CLINICAL INSTRUCTOR

Ms. Glenda S. Dilan, RN

Presented By:

Silvano, Janeenne Fe Nicole B.

Rubellano, Dhana Angela M.
Singson, Elaine Franz L.
Relacion, Eden Claire P.
Racman, Ella Maica L.
Razonable, Clendon S.
Waling, Eric Crizza C.
Senajon, Rei Louie G.
Tubac, Sheila Mae M.
Somosot, Jessa M.
April 27, 2023
Background

Dengue is the most common and important arthropod-borne viral (arboviral) illness in
humans. Globally, 2.5-3 billion individuals live in approximately 112 countries that experience
dengue transmission. While the annual incidence is unclear owing to incomplete global reporting
and misclassification of illness, approximately 3.2 million individuals were infected globally in
2015. Dengue is caused by infection with 1 of the 4 serotypes of dengue virus, which is a
Flavivirus (a genus of single-stranded non segmented RNA viruses). Infection with one dengue
serotype confers lifelong homotypic immunity to that serotype and a brief period (approximately
2 years) of partial heterotypic immunity to other serotypes, but an individual can eventually be
infected by all 4 serotypes. Several serotypes can be in circulation during an epidemic.
The global incidence of dengue has increased dramatically since the late 1900s, with an
estimated 40-50% of the world’s population in 128 countries at risk. Today, severe dengue
largely affects Asian and Latin American countries, where it is a leading cause of hospitalization
and death. The World Health Organization (WHO) ranked dengue as one of the top 10 threats to
global health in 2019. 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).
Classic dengue fever is marked by rapid onset of high fever, headache, retro-orbital pain, diffuse
body pain (both muscle and bone), weakness, vomiting, sore throat, altered taste sensation, and a
centrifugal maculopapular rash, among other manifestations. The severity of the pain led to the
term breakbone fever to describe dengue.

A small percentage of persons who have previously been infected by 1 dengue serotype
develop bleeding and endothelial leak upon infection with another dengue serotype. This
syndrome is termed severe dengue (reclassified in 2009 by the WHO, previously referred to as
dengue hemorrhagic fever and dengue shock syndrome). Severe dengue has also been termed
dengue vasculopathy. Vascular leakage in these patients results in hemoconcentration and serous
effusions and can lead to circulatory collapse. This, in conjunction with severe hemorrhagic
complications, can lead to a shock syndrome, which poses a greater fatality risk than bleeding
per se.

Dengue virus transmission follows 2 general patterns: epidemic dengue and

hyperendemic dengue. Epidemic dengue transmission occurs when dengue virus is introduced
into a region as an isolated event that involves a single viral strain. If the number of vectors and
susceptible pediatric and adult hosts is sufficient, explosive transmission can occur, with an
infection incidence of 25-50%. Mosquito-control efforts, changes in weather, and herd immunity
contribute to the control of these epidemics. Transmission appears to begin in urban centers and
then spreads to the rest of the country. [12] This is the current pattern of transmission in parts of
Africa and South America, areas of Asia where the virus has reemerged, and small island
nations. Travelers to these areas are at increased risk of acquiring dengue during these periods of
epidemic transmission.
Etiology

Dengue is a viral disease caused by any of the four serotypes of the dengue virus (DENV-
1, DENV-2, DENV-3, and DENV-4), which are members of the Flaviviridae family. The virus is
primarily transmitted to humans through the bite of infected Aedes mosquitoes, particularly
Aedes aegypti.

When a mosquito feeds on a person infected with the dengue virus, the virus enters the
mosquito's gut and replicates there. After about a week, the virus spreads to the mosquito's
salivary glands, from where it can be transmitted to a new host when the mosquito feeds again.
The virus can also be transmitted through blood transfusions, organ transplants, and from mother
to child during childbirth.
Various factors contribute to the spread of dengue, including urbanization, population
growth, travel, and inadequate mosquito control. Climate change and extreme weather events
such as El Niño can also influence the incidence of dengue by affecting mosquito populations
and their distribution.

Symptoms
Many people experience no signs or symptoms of a dengue infection.When symptoms do occur,
they may be mistaken for other illnesses — such as the flu — and usually begin four to 10 days
after you are bitten by an infected mosquito.
Dengue fever causes a high fever — 104 F (40 C) — and any of the following signs and
symptoms:
 Headache
 Muscle, bone or joint pain
 Nausea
 Vomiting
 Pain behind the eyes
 Swollen glands
 Rash
Most people recover within a week or so. In some cases, symptoms worsen and can become life-
threatening. This is called severe dengue, dengue hemorrhagic fever or dengue shock syndrome.
Severe dengue happens when your blood vessels become damaged and leaky. And the number of
clot-forming cells (platelets) in your bloodstream drops. This can lead to shock, internal
bleeding, organ failure and even death.
Warning signs of severe dengue fever — which is a life-threatening emergency — can develop
quickly. The warning signs usually begin the first day or two after your fever goes away, and
may include:
 Severe stomach pain
  Persistent vomiting
 Bleeding from your gums or nose
 Blood in your urine, stools or vomit
 Bleeding under the skin, which might look like bruising
 Difficult or rapid breathing
 Fatigue
 Irritability or restlessness

Causes
Dengue fever is caused by any one of four types of dengue viruses. You can't get dengue
fever from being around an infected person. Instead, dengue fever is spread through mosquito
bites. The two types of mosquitoes that most often spread the dengue viruses are common both in
and around human lodgings. When a mosquito bites a person infected with a dengue virus, the
virus enters the mosquito. Then, when the infected mosquito bites another person, the virus
enters that person's bloodstream and causes an infection.
After you've recovered from dengue fever, you have long-term immunity to the type of
virus that infected you — but not to the other three dengue fever virus types. This means you can
be infected again in the future by one of the other three virus types. Your risk of developing
severe dengue fever increases if you get dengue fever a second, third or fourth time.
Risk factors
You have a greater risk of developing dengue fever or a more severe form of the disease if:
 You live or travel in tropical areas. Being in tropical and subtropical areas increases your
risk of exposure to the virus that causes dengue fever. Especially high-risk areas include
Southeast Asia, the western Pacific islands, Latin America and Africa.
 You have had dengue fever in the past. Previous infection with a dengue fever virus
increases your risk of severe symptoms if you get dengue fever again.
Complications
Severe dengue fever can cause internal bleeding and organ damage. Blood pressure can drop to
dangerous levels, causing shock. In some cases, severe dengue fever can lead to death. Women
who get dengue fever during pregnancy may be able to spread the virus to the baby during
childbirth. Additionally, babies of women who get dengue fever during pregnancy have a higher
risk of pre-term birth, low birth weight or fetal distress.
Pathophysiology
Dengue fever is a mosquito-borne viral disease caused by 1 of 4 closely related but
antigenically distinct serotypes of dengue virus, serotypes DENV-1 through DEN-4. Infection
with 1 dengue serotype confers lifelong homotypic immunity and a brief period of partial
heterotypic immunity (2 years), but each individual eventually can be infected by all 4 serotypes.
Several serotypes can be in circulation during an epidemic.
The Aedes mosquito
Dengue viruses are transmitted by the bite of an infected
female Aedes (subgenus Stegomyia) mosquito. Both males and females require nectar for
energy. Females require a blood meal as a source of appropriate protein for egg development.
Globally, Aedes aegypti is the predominant highly efficient mosquito vector for dengue
infection, but the Asian tiger mosquito, Aedes albopictus, and other Aedes species can
also transmit dengue with varying degrees of efficiency.

Aedes mosquito species have adapted well to human habitation, often breeding around
dwellings in small amounts of stagnant water found in old tires or other small containers
discarded by humans. Even a bottle cap filled with water can serve to incubate and
hatch Aedes eggs. Eggs can survive periods of drying and will hatch when exposed to water.
Humans are the preferred hosts. Female Aedes mosquitoes are daytime feeders. They inflict an
innocuous bite, usually on the back of the neck and the ankles, and are easily disturbed during a
blood meal, causing them to move on to finish a meal on another individual, making them
efficient vectors. Not uncommonly, entire families develop infection within a 24- to 36-hour
period, presumably from the bites of a single infected mosquito.
Hosts for transmission
Humans serve as the primary reservoir for dengue. Certain nonhuman primates in Africa
and Asia also serve as hosts but do not develop dengue hemorrhagic fever. Mosquitoes acquire
the virus when they feed on a carrier of the virus. Persons with dengue viruses in their blood can
transmit the viruses to the mosquito 1 day before the onset of the febrile period. The patient
usually remains infectious for the subsequent 4-5 days (up to 12 days). The mosquito can
transmit dengue if it immediately bites another host. In addition, transmission occurs after 8-12
days of viral replication in the mosquito's salivary glands (extrinsic incubation period). The virus
does not adversely affect the mosquito. The mosquito remains infected for the remainder of its
life. The life span of A aegypti usually is 21 days but ranges from 15 to 65 days. Vertical
transmission of dengue virus in mosquitoes has been documented. The eggs of Aedes mosquitoes
withstand long periods of desiccation, reportedly as long as 1 year, but are killed by temperatures
of less than 10°C. Rare cases of vertical dengue transmission have been reported. In addition,
rare reports of human-to-human transmission via needle-stick injuries have been
published. Dengue rarely has been described as transmitted by breast milk or by sexual
transmission, though these are not common or significant modes of transmission.

Once inoculated into a human host, dengue has an incubation period of 3-14 days,
(average 4-7 days) whereas viral replication takes place in target dendritic cells. Infection of
target cells, primarily those of the reticuloendothelial system, such as dendritic cells,
macrophages, hepatocytes, and endothelial cells, result in the production of immune mediators
that serve to shape the quantity, type, and duration of cellular and humoral immune response to
both the initial and subsequent virus infections. Dengue viral infections frequently are not
apparent. In most cases, especially in children younger than 15 years, the patient is asymptomatic
or has a mild undifferentiated febrile illness lasting 5-7 days. Classic dengue fever primarily
occurs in nonimmune, nonindigenous adults and children and is typically self-limiting. Recovery
usually is complete in 7-10 days. Severe dengue (dengue hemorrhagic fever/dengue shock
syndrome) usually occur around the third to seventh day of illness during a second dengue
infection in persons with preexisting actively or passively (maternally) acquired immunity to a
heterologous dengue virus serotype.

Dengue fever
Dengue presents in a nonspecific manner similarly to that of many other viral and
bacterial illnesses. Fever typically begins on the third day of illness and persists 5-7 days, abating
with the cessation of viremia. Fever may reach 41C°. Occasionally, and more frequently in
children, the fever abates for a day and recurs, a pattern that is termed a saddleback fever;
however, this pattern more commonly is seen in dengue hemorrhagic fever. Leukopenia,
lymphopenia near the end of the febrile phase, and thrombocytopenia are common findings in
dengue fever and are believed to be caused by direct destructive actions of the virus on bone
marrow precursor cells. The resulting active viral replication and cellular destruction in the bone
marrow are believed to cause the bone pain. Approximately one third of patients with dengue
fever may have mild hemorrhagic symptoms, including petechiae, gingival bleeding, and a
positive tourniquet test (>20 petechiae in an area of 2.5 X 2.5 cm). Dengue fever rarely is fatal.

Severe dengue (dengue hemorrhagic fever)

Severe dengue occurs less frequently than dengue fever but has a more dramatic clinical
presentation. In most of Asia, where it first was described, severe dengue primarily is a disease
of children. However, in the Americas, and more recently reported in Taiwan, severe dengue has
an equal distribution in all ages. Severe dengue typically begins with the initial manifestations of
dengue fever. The acute febrile illness (temperatures ≤40°C), like that of dengue fever, lasts
approximately 2-7 days. However, in persons with severe dengue, the fever reappears, giving a
biphasic or saddleback fever curve.
Along with biphasic fever, patients with severe dengue have progressive
thrombocytopenia, increasing hematocrit (20% absolute rise from baseline) and low albumin
(signs of hemoconcentration preceding shock), more obvious hemorrhagic manifestations (>50%
of patients have a positive tourniquet test), and progressive effusions (pleural or peritoneal).
Lymphocytosis, often with atypical lymphocytes, commonly develops before defervescence or
the onset of shock. Transaminase levels may be mildly elevated or present in the several
thousands associated with hepatomegaly in those patients with acute hepatitis. Low fibrinogen
and elevated fibrin split products are signs of disseminated intravascular coagulation. Severe
metabolic acidosis and circulatory failure can occur.

The critical feature of severe dengue is plasma leakage. Plasma leakage is caused by
increased capillary permeability and may manifest as hemoconcentration, as well as pleural
effusion and ascites. Bleeding is caused by capillary fragility and thrombocytopenia and may
manifest in various forms, ranging from petechial skin hemorrhages to life-threatening
gastrointestinal bleeding. Liver damage manifests as increases in levels of alanine
aminotransferase and aspartate aminotransferase, low albumin levels, and deranged coagulation
parameters (prothrombin time, partial thromboplastin time). In persons with fatal dengue
hepatitis, infection was demonstrated in more than 90% of hepatocytes and Kupffer cells with
minimal cytokine response (tumor necrosis factor [TNF]–alpha, interleukin [IL]–2). This is
similar to that seen with fatal yellow fever and Ebola infections.

As the term implies, severe dengue shock is essentially dengue hemorrhagic fever with
progression into circulatory failure, with ensuing hypotension, narrow pulse pressure (< 20 mm
Hg), and, ultimately, shock and death if left untreated. Death may occur 8-24 hours after onset of
signs of circulatory failure. The most common clinical findings in impending shock include
hypothermia, abdominal pain, vomiting, and restlessness.

Laboratory Diagnostic and Diagnostic tests

Efficient and accurate diagnosis of dengue is of primary importance for clinical care (i.e. early
detection of severe cases, case confirmation and differential diagnosis with other infectious
diseases), surveillance activities, outbreak control, pathogenesis, academic research, vaccine
development, and clinical trials.

Laboratory diagnosis methods for confirming dengue virus infection may involve detection of
the virus, viral nucleic acid, antigens or antibodies, or a combination of these techniques. After
the onset of illness, the virus can be detected in serum, plasma, circulating blood cells and other
tissues for 4–5 days. During the early stages of the disease, virus isolation, nucleic acid or
antigen detection can be used to diagnose the infection. At the end of the acute phase of
infection, serology is the method of choice for diagnosis.

Antibody response to infection differs according to the immune status of the host . When dengue
infection occurs in persons who have not previously been infected with a flavivirus or
immunized with a flavivirus vaccine (e.g. for yellow fever, Japanese encephalitis, tick-borne
encephalitis), the patients develop a primary antibody response characterized by a slow increase
of specific antibodies. IgM antibodies are the first immunoglobulin isotype to appear. These
antibodies are detectable in 50% of patients by days 3-5 after onset of illness, increasing to 80%
by day 5 and 99% by day 10. IgM levels peak about two weeks after the onset of symptoms and
then decline generally to undetectable levels over 2–3 months. Anti-dengue serum IgG is
generally detectable at low titres at the end of the first week of illness, increasing slowly
thereafter, with serum IgG still detectable after several months, and probably even for life (2–4).
During a secondary dengue infection (a dengue infection in a host that has previously been
infected by a dengue virus, or sometimes after non-dengue flavivirus vaccination or infection),
antibody titres rise rapidly and react broadly against many flaviviruses. The dominant
immunoglobulin isotype is IgG which is detectable at high levels, even in the acute phase, and
persists for periods lasting from 10 months to life. Early convalescent stage IgM levels are
significantly lower in secondary infections than in primary ones and may be undetectable in
some cases, depending on the test used (5). To distinguish primary and secondary dengue
infections, IgM/IgG antibody ratios are now more commonly used than the haemagglutination-
inhibition test (HI) (6–8).

laboratory diagnostic methods has been developed to support patient management and disease
control. The choice of diagnostic method depends on the purpose for which the testing is done
(e.g. clinical diagnosis, epidemiological survey, vaccine development), the type of laboratory
facilities and technical expertise available, costs, and the time of sample collection.

Medical Management
 - No specific medication for dengue fever
- Symptomatic and supportive treatment

1. Mild analgesic-antipyretics.

2. Oral rehydrating salt

3. Sodium bicarbonate

- to treat acidosis, if not treated, may lead to disseminated intravascular coagulation

AVOID:

- Aspirin
- Nonsteroidal anti-inflammatory drugs
- Corticosteroids

FLUIDS MANAGEMENT

1. Oral rehydration therapy

- recommended for patients with moderate dehydration caused by high fever and vomiting.

2. IV fluids (0.9 saline or ringers lactate solution)

- patients with increasing HCT, evidence of ongoing plasma leakage, despite increased oral intake.

- patient who are vomiting, severe diarrhea and not tolerating orally.

3. Blood transfusion and blood products.

- blood transfusion for internal or gastrointestinal bleeding

- fresh frozen plasma for patients with coagulopathy

WHEN TO CONSIDER SEVERE DENGUE

  Severe plasma leakage
- Patient has hypovolemic shock
- Patient has respiratory distress due to fluid accumulation, either pleural effusion or ascites
 Severe bleeding
- Patient remains in shock despite IV isotonic crystalloid solution and the hematocrit is decreasing
- Bleeding can be occult and not recognized in a timely manner, important to do frequent vital
signs and monitoring hematocrit
- Bleeding usually occurs in the gastrointestinal tract, and only rarely in the brain
- Severe bleeding exacerbates shock
 Severe organ impairment
- Such as liver, kidney and brain has been observed in patient with only mild or no plasma leakage
or after the critical phase of dengue
- Liver enzymes are frequently elevated during the critical and recovery phases.
- Consequences of hypovolemic shock
- Impaired consciousness
- Impaired cardiac function – raised cardiac enzymes with reduced left ventricular function

Dengue fever usually is a self-limited illness. There is no specific antiviral treatment available
for dengue fever. The World Health Organization (WHO) has provided a number of
Supportive care with analgesics, fluid replacement, and bed rest usually is sufficient.
Acetaminophen may be used to treat fever and relieve other symptoms. Aspirin, nonsteroidal
anti-inflammatory drugs (NSAIDs), and corticosteroids should be avoided. Management of
severe dengue requires careful attention to fluid management and proactive treatment of
hemorrhage.
Suspected Dengue
Oral rehydration therapy is recommended for patients with moderate dehydration caused by high
fever and vomiting. Patients with known or suspected dengue fever should have their platelet
count and hematocrit measured daily from the third day of illness until 1-2 days after
defervescence. Patients with clinical signs of dehydration and patients with a rising hematocrit
level or falling platelet count should have intravascular volume deficits replaced under close
observation. Those who improve can continue to be monitored in an outpatient setting, and those
who do not improve should be admitted to the hospital for continued hydration.
Patients who develop signs of dengue hemorrhagic fever warrant closer observation. Admission
for intravenous fluid administration is indicated for patients who develop signs of dehydration,
such as the following:
* Tachycardia
* Prolonged capillary refill time
* Cool or mottled skin
* Diminished pulse amplitude
* Altered mental status
* Decreased urine output
* Rising hematocrit
* Narrowed pulse pressure
* Hypotension

Severe Dengue
Successful management of severe dengue requires careful attention to fluid management and
proactive treatment of hemorrhage. Admission to an intensive care unit is indicated for patients
with dengue shock syndrome.

Patients may need a central intravenous line for volume replacement and an arterial line for
accurate blood pressure monitoring and frequent blood tests. Exercise caution when placing
intravascular catheters because of the increased bleeding complications of dengue hemorrhagic
fever. Urethral catheterization may be useful to strictly monitor urine output.

Intravascular volume deficits should be corrected with isotonic fluids such as Ringer lactate
solution. Boluses of 10-20 mL/kg should be given over 20 minutes and may be repeated. If this
fails to correct the deficit, the hematocrit value should be determined. If it is rising, limited
clinical information suggests that a plasma expander may be administered. Starch, dextran 40, or
albumin 5% at a dose of 10-20 mL/kg may be used. One study has suggested that starch may be
preferable because of hypersensitivity reactions to dextran.
If the patient does not improve after infusion of a plasma expander, blood loss should be
considered. Patients with internal or gastrointestinal bleeding may require transfusion, and
patients with coagulopathy may require fresh frozen plasma.

After patients with dehydration are stabilized, they usually require intravenous fluids for no more
than 24-48 hours. Intravenous fluids should be stopped when the hematocrit falls below 40% and
adequate intravascular volume is present. At this time, patients reabsorb extravasated fluid and
are at risk for volume overload if intravenous fluids are continued. Do not interpret a falling
hematocrit value in a clinically improving patient as a sign of internal bleeding.

Platelet and fresh frozen plasma transfusions may be required to control severe bleeding. A case
report demonstrated good improvement following intravenous anti-D globulin administration in
2 patients. The authors proposed that, as in immune thrombocytopenic purpura from disorders
other than dengue, intravenous anti-D produces Fcγ receptor blockade to raise platelet counts.

Patients who are resuscitated from shock rapidly recover. Patients with dengue hemorrhagic
fever or dengue shock syndrome may be discharged from the hospital when they meet the
following criteria:

* Afebrile for 24 hours without antipyretics

* Good appetite, clinically improved condition
* Adequate urine output
* Stable hematocrit level
* At least 48 hours since recovery from shock
* No respiratory distress
* Platelet count greater than 50,000 cells/μL

Pregnant patients
Dengue in pregnancy must be carefully differentiated from preeclampsia. An overlap of
signs and symptoms, including thrombocytopenia, capillary leak, impaired liver function, ascites,
and decreased urine output may make this clinically challenging. Pregnant women with dengue
fever respond well to the usual therapy of fluids, rest, and antipyretics. However, 3 cases of
maternal death due to dengue fever in the third trimester have been reported. An awareness of the
clinical and laboratory manifestations of dengue in pregnancy should allow its early recognition
and the institution of appropriate treatment. If the mother acquires infection in the peripartum
period, newborns should be evaluated for dengue with serial platelet counts and serologic
studies.

Diet and Activity

No specific diet is necessary for patients with dengue fever. Patients who are able to tolerate oral
fluids should be encouraged to drink oral rehydration solution, fruit juice, or water to prevent
dehydration from fever, lack of oral intake, or vomiting. Return of appetite after dengue
hemorrhagic fever or dengue shock syndrome is a sign of recovery.

Bed rest is recommended for patients with symptomatic dengue fever, dengue hemorrhagic fever,
or dengue shock syndrome. Permit the patient to gradually resume their previous activities,
especially during the long period of convalescence.

Prevention
The only way to truly prevent dengue virus acquisition is to avoid being bitten by a
vector mosquito. Although this can be accomplished by avoiding travel to areas where dengue is
endemic, that is not an ideal strategy because it would require a person to avoid most tropical and
subtropical regions of the world, many of which are popular travel and work destinations. Other
measures are as follows:
* Wear N,N-diethyl-3-methylbenzamide (DEET)–containing mosquito repellant
* Wear protective clothing, preferably impregnated with permethrin insecticide
* Remain in well-screened or air-conditioned places
* The use of mosquito netting is of limited benefit, as Aedes are day-biting mosquitoes
* Eliminate the mosquito vector using indoor sprays

Consultations
Consultation with an infectious diseases specialist may be helpful in guiding decisions
regarding diagnosis and treatment. Consultation with a critical care medicine specialist may be
helpful when treating patients with dengue hemorrhagic fever or dengue shock syndrome and
severe hemorrhagic manifestations or shock.
Nursing Management

Nursing Assessment
Assessment of a patient with DF 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.

Nursing Interventions
Nursing Interventions appropriate for a patient with DF include:
 Blood pressure monitoring
 Note client report of pain in specific areas, whether pain is increasing, diffused, or
localized.
 Maintain patency of vascular access for fluid administration or blood replacement as
indicated.
 Medication regimen
 If nose bleeds occur elevate position of the patient and apply ice bag to the bridge of the
nose and to the forehead.
 Place the patient in Trendelenburg position to restore blood volume to the head.

What to eat and drink?

 Drink plenty of water or fluid to hydrate the body and to maintain water and electrolytes
balance.
 High Calorie Diet such as rice, potato, milk and etc. to help regain strength and energy
lost due to the infection.
 Iron-rich foods like meats, legumes, and green leafy vegetables to increase blood
hemoglobin and the formation of platelets bleeding and blood loss.
 Vitamin C-rich foods like citrus fruits, pineapple, papaya, and etc. help in the absorption
of iron by the intestine, Also, it has antiviral and antibacterial properties which boost and
strengthen the immune system.
 Vitamin K-rich foods is essential for blood clotting and increases platelet counts which
were reduces during dengue fever.
 What to avoid?
 Dark-colored foods like chocolate, drinks and violet or red-colored juice. It may cause
confusion by altering the color of the vomitus, urine or stool
 Fatty foods, it reduces digestive capacity making it difficult for dengue patients to digest
fats.
 Spicy foods because it can build-up acid in the stomach which can irritate the stomach
wall and increases risk for gastrointestinal bleeding.
 Caffeinated beverages such as coffee, tea, energy drinks, can lead to dehydration and
muscle breakdown.

Discharge and Home Care Guidelines

A patient with DF discharged from the health care facility be instructed to:
 Avoid caffeine and alcohol as indicated to reduce effect of diuresis.
 Comply with recommended medical and laboratory follow-up appointments.
 Recommend use of soft toothbrush to reduce risk of injury to the oral mucosa.
 Foods rich in vitamin K should be recommended to promote blood clotting.
 Educate patient on the use of mosquito nets, insecticides and symptoms of dengue fever.

HEALTH TEACHINGS
No specific treatment is available for dengue fever. Mild cases are managed with lots
of fluids to prevent dehydration and get plenty of rest. Pain relievers with acetaminophen can
ease the headaches and pain from dengue fever. Pain relievers with aspirin or ibuprofen
should be avoided, as they can make bleeding more likely. Most cases of dengue fever go
away within a week or two and won't cause any lasting problems. If someone has severe
symptoms of the disease, or if symptoms get worse in the first day or two after the fever goes
away, get medical care right away. This could be an indication of DHF, which is a medical
emergency. To treat severe cases of dengue fever at a hospital, doctors will give intravenous
(IV) fluids and electrolytes (salts) to replace those lost through vomiting or diarrhea. When
started early, this is usually enough to effectively treat the disease. In more advanced cases,
doctors may have to do a blood transfusion. In all cases of dengue infection, efforts should be
made to keep the infected person from being bitten by mosquitoes. This will help prevent the
illness from spreading to others.
Preventing Dengue Fever
The best way to prevent the disease is to prevent bites by infected mosquitoes, particularly
if you are living in or traveling to a tropical area. This involves protecting yourself and making
efforts to keep the mosquito population down. In 2019, the FDA approved a vaccine called
Dengvaxia to help prevent the disease from occurring in adolescents aged 9 to 16 who have
already been infected by dengue. But, there currently is no vaccine to prevent the general
population from contracting it.
To protect yourself:
 Use mosquito repellents, even indoors.
 When outdoors, wear long-sleeved shirts and long pants tucked into socks.
 When indoors, use air conditioning if available.
 Make sure window and door screens are secure and free of holes. If sleeping areas are not
screened or air conditioned, use mosquito nets.
 If you have symptoms of dengue, speak to your doctor.
To reduce the mosquito population, get rid of places where mosquitoes can breed. These
include old tires, cans, or flower pots that collect rain. Regularly change the water in outdoor
bird baths and pets' water dishes. If someone in your home gets dengue fever, be especially
vigilant about efforts to protect yourself and other family members from mosquitoes. Mosquitoes
that bite the infected family member could spread the infection to others in your home.
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 for hemorrhage.