DENGUE FEVER WITH WARNING SIGNS

____________________

A Case Study

Presented to the Faculty of the

COLLEGE OF NURSING

____________________

In Partial Fulfillment

of the Requirements for the Subject

RELATED LEARNING EXPERIENCE

____________________

Presented by:

Aberin, John Winston P.

BSN 3-6 | Group 1

Presented to:

Archito Lajom Dela Cruz, MAN, RN

RLE Level 3 and Quality Assurance Coordinator

November 2024
CHAPTER I. THE PROBLEM AND ITS SETTINGS
OBJECTIVES OF THE CASE
A. General Objective
To comprehensively assess, diagnose, plan, implement, and
evaluate nursing care for a 5-year-old pediatric patient
diagnosed with dengue fever with warning signs, focusing on
providing safe, effective nursing interventions to promote
recovery and prevent complications. Additionally, to enhance
understanding of dengue fever, its pathophysiology, clinical
manifestations, and effective management strategies to prevent
disease progression and associated complications.

B. Specific Objectives
1. To identify and assess the patient’s clinical
manifestations and warning signs of dengue fever.
2. To develop appropriate nursing diagnoses based on
patient assessment and lab results.
3. To implement a nursing care plan focusing on managing
dengue fever symptoms and preventing complications.
4. To educate the patient's caregivers about the
disease, its management, and preventive measures.
5. To evaluate the effectiveness of the nursing
interventions and modify the plan of care as needed.
6. To promote patient safety, including minimizing the
risk of bleeding due to low platelet count.
INTRODUCTION
A. What is a Case Study?
A case study is a detailed account of a specific patient,
condition, or event designed to analyze clinical and nursing
management in real-world settings. It serves as an educational
tool for future nurses by enhancing their critical thinking and
decision-making skills, enabling them to apply theoretical
knowledge to real-life situations. For future RNs, case studies
are essential because they highlight how evidence-based practice
is integrated into patient care, facilitating improved outcomes.

B. Introduction about the Case

This case focuses on a 5-year-old male patient diagnosed
with dengue fever with warning signs, admitted due to persistent
fever and abdominal pain. The clinical impression is based on
laboratory results showing thrombocytopenia (a low platelet
count of 25), which indicates a severe form of dengue fever. The
case explores nursing interventions, medical management, and the
importance of patient education in preventing complications,
such as bleeding, which are common in dengue patients with
critically low platelet counts.

Dengue fever is an acute viral infection caused by the

dengue virus, which is transmitted through the bite of infected
Aedes mosquitoes, particularly Aedes aegypti and Aedes
albopictus. The disease is common in tropical and subtropical
regions worldwide (WHO, 2020). Dengue fever typically presents
with flu-like symptoms such as high fever, severe headache,
muscle and joint pains, nausea, vomiting, and rash. In some
cases, it progresses to a more severe form known as dengue
hemorrhagic fever (DHF) or dengue shock syndrome (DSS),
characterized by increased vascular permeability,
thrombocytopenia, and bleeding. Early recognition and timely
management of warning signs, such as persistent abdominal pain,
thrombocytopenia, and bleeding, are critical in preventing
complications and reducing mortality associated with severe
dengue.
C. Incidence (International-WHO; Local-DOH)
Dengue fever is a viral infection transmitted by the Aedes
mosquito, predominantly found in tropical and subtropical
regions. According to the World Health Organization (WHO),
approximately 100-400 million dengue infections occur annually
worldwide, with about 2.5% of those cases progressing to severe
forms such as dengue hemorrhagic fever (DHF) (WHO, 2020). In the
Philippines, dengue is endemic, with thousands of cases reported
each year. The Department of Health (DOH) recorded around 170,000
cases in 2023, with a mortality rate of 0.4%, emphasizing the
need for early detection and management of warning signs to
reduce mortality (DOH, 2023).
D. Theoretical Framework

Figure 1.0 Betty Neuman’s System Model

The Neuman Systems Model by Betty Neuman is applicable in
the care of this patient. The Neuman Systems Model focuses on
the patient as an open system that interacts with internal and
external stressors. Dengue fever presents as an external
stressor, threatening the stability of the patient’s system. The
role of nursing in this case is to maintain the patient’s
stability by identifying the stressors (dengue virus, low
platelet count) and intervening to prevent further
destabilization through symptom management, education, and
supportive care (Tortora & Derrickson, 2019).

E. Review of Related Literature and Studies

1. Dengue Fever in Pediatric Populations
According to a study by Ahmad et al. (2020), children are
at higher risk for severe forms of dengue fever, especially those
younger than 10 years old. The study highlights the importance
of early intervention and aggressive management in children with
warning signs such as thrombocytopenia and persistent abdominal
pain. It emphasizes that delayed diagnosis often leads to
complications like bleeding, shock, and multi-organ failure,
which are preventable with timely care (Ahmad et al., 2020).
2. Management of Dengue with Warning Signs
A study by Santos et al. (2021) examined nursing care for
pediatric patients with dengue fever with warning signs. The
research stressed the importance of monitoring vital signs,
fluid balance, and laboratory parameters, such as platelet
counts and coagulation profiles, to prevent severe
complications. Nurses play a crucial role in educating the family
about warning signs, ensuring adequate hydration, and promoting
rest to aid recovery. (Ahmad, R., et al., 2020; Santos, L., et
al., 2021)
3. Fluid Management with Dengue Fever
A study by Ranjan and Ghosh (2022) emphasized the critical role
of fluid management in preventing complications of dengue fever,
especially in pediatric patients. Proper hydration helps
maintain vascular stability and prevent hypovolemic shock, a
common complication in severe dengue cases. The study also noted
that overhydration must be avoided as it can lead to fluid
overload, worsening plasma leakage and increasing the risk of
respiratory distress. This highlights the need for careful
monitoring of fluid intake and output, alongside regular
assessment of hematocrit levels to guide fluid therapy (Ranjan
& Ghosh, 2022).

CLIENT’S PROFILE
Name CTM

Address Cabanatuan City, Nueva Ecija

Age 5 years old

Gender Male

Religion Catholic

Occupation Student

Reason for
Fever 4 days PTA (prior to admission)
Seeking Care

Date of
October 6, 2024
Admission

Ethnicity Filipino

The patient was brought to the hospital with the

Admitting complaint of fever and abdominal pain, persisting for
History 4 days. Symptoms continued despite treatment at home,
prompting the consult in the hospital.

Final Clinical impression of dengue fever with warning

Diagnosis signs (low platelet count and abdominal pain).

Table 1.1 Client’s Profile

SUBJECTIVE DATA COLLECTION
COMPREHENSIVE NURSING HEALTH HISTORY
A. History of Present Illness
The patient, CTM, a 5-year-old male, was admitted on
October 6, 2024, with a 4-day history of fever and abdominal
pain. Initially, the fever was managed at home with over-the-
counter medications, but the persistence of symptoms,
particularly the abdominal pain, prompted his parents to seek
medical attention. The family resides in an area known to have
a high prevalence of mosquitoes, particularly during the rainy
season, which increases the risk of mosquito-borne diseases such
as dengue fever. On admission, laboratory tests revealed a low
platelet count of 25, significantly below the normal range,
indicating the clinical impression of dengue fever with warning
signs. As of October 9, 2024, the patient’s fever has subsided,
and his vital signs are within normal ranges, but the
thrombocytopenia persists, placing him at risk for bleeding.
B. History of Past Illness
CTM has no significant history of previous illnesses,
hospitalizations, surgeries, or chronic conditions. His
vaccination status is up to date, and there is no history of
allergies or known medical conditions prior to the current
illness. He had occasional colds and minor respiratory
infections in the past, which were treated conservatively at
home.
 C. Family History
There is no known history of
dengue fever in the family.
Both parents are in good
health, with no chronic
illnesses such as
hypertension, diabetes, or
genetic disorders. The family
resides in Cabanatuan City,
Nueva Ecija, an area known for
periodic dengue outbreaks
during the rainy season. The
patient lives with both parents
and a younger sibling.
Figure 1.1 Genogram
The family history does not reveal any hereditary diseases that
could contribute to CTM’s condition.

GORDON’S FUNCTIONAL HEALTH PATTERNS

A. Health Perception-Health Management Pattern
CTM, a 5-year-old male, has generally been perceived as a
healthy child by his parents, with no previous significant health
issues. His health has been managed primarily through regular
vaccinations and check-ups. His parents have been vigilant in
ensuring he follows a healthy routine, which includes a balanced
diet and adequate rest. In this current illness, the parents
quickly sought medical care when the symptoms of fever and
abdominal pain persisted, showing an appropriate health
management behavior in response to the signs of dengue fever.
The family follows preventive health measures, such as mosquito
control and regular use of insect repellent, to reduce the risk
of dengue infection.
 B. Cognitive-Perceptual Pattern
CTM’s cognitive and sensory development is appropriate for
his age. He is alert, oriented, and able to communicate his
discomfort, such as abdominal pain. He can follow simple
instructions and interact well with others. There are no reported
issues with his vision or hearing, and his sensory perception
remains intact. Cognitive functions such as attention, memory,
and comprehension are within normal limits for his developmental
stage.

C. Self-Perception-Self Concept Pattern

CTM has a positive self-concept typical for a child of his
age. He enjoys school and interacts well with his peers. Although
he is currently ill, there have been no noticeable changes in
his perception of self. He expresses discomfort due to his
illness but does not exhibit any signs of anxiety or fear related
to his body image or health. He remains confident and playful
when interacting with family members and healthcare staff.

D. Role-Relationship Pattern
CTM is the eldest of two siblings and plays an active role
within his family. He is affectionate toward his parents and
younger sibling, often taking on the role of "big brother." At
school, he engages well with his classmates and teachers. His
parents describe him as sociable and cooperative. Currently,
CTM’s parents are very involved in his care, ensuring that his
health needs are met, and he is surrounded by a supportive family
environment during his hospitalization.

E. Sexuality-Reproductive Pattern
As a 5-year-old child, CTM’s reproductive patterns are not
yet relevant. His relationship with his body is focused on growth
and physical development appropriate to his age.
 F. Value-Belief Pattern
CTM comes from a Catholic family that practices traditional
religious beliefs. The family often prays together, and
spiritual values are central to their moral decision-making. CTM
has been taught basic religious practices, such as praying before
meals. His parents believe in the power of prayer and have
expressed hope for his recovery, incorporating their faith into
their care for him.

G. Nutritional-Metabolic Pattern
CTM’s nutritional intake is generally balanced and
appropriate for his age, consisting of regular meals that include
rice, vegetables, proteins, and fruits. His parents report that
he drinks an adequate amount of water daily and enjoys a variety
of foods. As per the 24-hour food recall:
● Breakfast: 1 cup of rice, scrambled egg, and a glass of
milk
● Lunch: Chicken soup with vegetables and 1 cup of rice
● Dinner: Rice, fish, and fruit
Currently, with his illness, his appetite is slightly
reduced but not significantly impaired. His fluid intake is
closely monitored to prevent dehydration, a common complication
in dengue fever.

H. Elimination Pattern
CTM has normal bowel and bladder functions. His parents
report regular bowel movements once daily, and he urinates
frequently throughout the day with no issues such as pain or
burning. There have been no instances of vomiting, diarrhea, or
sweating, which are often concerns in cases of fever or
infections.

I. Activity-Exercise Pattern
Before his illness, CTM was an active child who enjoyed
playing outdoor games, running, and participating in school
activities. His usual daily routine involved physical activities
with friends at school and during recess. Since his admission,
his physical activity has been restricted due to fatigue and the
need for rest. The care team has encouraged minimal activity to
prevent further strain, given his low platelet count and the
risk of bleeding.

J. Sleep-Rest Pattern
CTM typically sleeps for 8-9 hours each night, which is
appropriate for his age. He has a regular bedtime and sleeps
through the night without disturbances. During his illness, he
has been resting more during the day, and taking naps due to
fatigue. His sleep quality has remained good despite his
hospitalization, and his parents report no significant changes
in his sleeping habits during this period.

ACTIVITIES OF DAILY LIVING

Activities Independence Dependence Patient’s

(1 Point) (0 Points) Status

Bathing Bathes self Needs help 0 Points.

completely or with bathing Requires
needs help in more than one assistance
bathing only a part of the with bathing
single part of body, getting and
the body in or out of brushing teeth
the tub or due
shower to fatigue and
potential risk
of
falling.

Dressing Get clothes Needs help 0 Points.

from the with dressing Needs help
closets and self or needs from
drawers and to be parents to
puts on completely choose
clothes and dressed. appropriate
outer garments clothing and
completely assist
with fasteners with putting
on
 clothes.

Toileting Goes to the Needs help 1 Point. Can

toilet, gets transferring use the toilet
on and off, to the toilet, independently
arranges cleaning self, but
clothes, or uses a may require
cleans genital bedpan or supervision to
area without commode ensure safety,
help especially
with
fatigue.

Transferring Moves in and Needs help in 0 Points.

out of bed or moving from Requires
chair bed to chair assistance
unassisted. or requires a when moving
Mechanical complete around
transfer aids transfer the hospital
are acceptable to
prevent falls;
walking is
limited
due to
fatigue.

Continence Exercises Is partially 1 Point.

complete self or totally Exercises
control over incontinent of complete self
urination and bowel or control over
defecation bladder urination and
defecation

Feeding Gets food from Needs partial 1 Point. Can

plate into or total help eat
mouth without with feeding independently,
help. or requires but
Preparation of parenteral supervision is
food may be feeding. provided to
done by ensure
another he is hydrated
person. and
eating enough.

Scoring: TOTAL POINTS:

6 - High (Patient 3 Points
Independent) Moderate Level of
0 - Low (Patient very Dependence
dependent)
Table 1.2. Katz Index of Independence in Activities of Daily
Living Table
Discussion:
CTM's activities of daily living indicate a mix of
independence and dependence due to his current condition. While
he can perform some tasks independently, he requires assistance
in several areas, especially those that may pose safety risks
or require supervision, such as bathing, dressing, and
transferring. This balance of independence and dependence
highlights the importance of parental involvement in his care
during his recovery from dengue fever.
OBJECTIVE DATA COLLECTION
GENERAL SURVEY
A. Physical Appearance
● Obvious Signs of Distress: The patient, CTM, a 5-
year-old male, shows no obvious signs of distress. He
does not appear to be in acute pain and is breathing
comfortably without shortness of breath (SOB) or
anxiety.
● Level of Consciousness (LOC): CTM is alert, awake,
and responsive to verbal stimuli. His LOC is
appropriate for his age.
● Skin Color and Condition: His skin is warm and dry,
with no pallor, cyanosis, or jaundice. There are no
rashes or petechiae noted, despite the low platelet
count.
● Facial Features: His facial features are symmetrical,
and there are no signs of facial drooping or other
abnormalities. He exhibits normal expressions for his
age.
● Body Structure: CTM has a well-proportioned body
structure for his age, with no obvious deformities or
abnormalities. His posture is relaxed when seated.
● Mobility: CTM is able to move all extremities freely.
He walks without assistance, though his activity is
restricted due to the risk of bleeding from his low
platelet count.
B. Behavior
● Mood and Affect: CTM appears jolly and cooperative
during the assessment. He interacts well with
healthcare providers and his family. His affect is
appropriate for his age, and he does not exhibit signs
of irritability or sadness.
 ● Speech: His speech is clear, coherent, and age-
appropriate. He responds to questions appropriately
and without hesitation.
● Dress and Grooming: CTM is dressed appropriately for
the hospital setting. His clothing is clean and well-
fitted. His grooming is maintained, with no signs of
neglect.
● Hygiene: His hygiene is well-maintained, with clean
skin, hair, and nails. There are no signs of poor
personal care.
● Eye Contact: CTM maintains eye contact during
conversations, demonstrating engagement and
attentiveness.
C. Body Measurements
Parameter Result
Height 106 cm (3 ft 5 in)
Weight 19 kg (41.9 lbs)
Body Mass Index 16.9 (within normal
range)
Table 1.3 Body Measurements
Discussion:
CTM’s BMI is within the normal range for a child of his
age, indicating appropriate growth and development. His
height and weight are proportionate for his age group.

Date Blood Temp Pulse Respirato Oxygen

Pressure Rate ry Rate Saturatio
n

10/09/24 90/60 36.6 C 109 BPM 26 BPM 98%

mmHg
Table 1.4 Vital Signs Table
Interpretation:
CTM's vital signs are within normal limits for a child
of his age. His blood pressure is stable, his heart rate
and respiratory rate are within appropriate ranges, and
 his oxygen saturation is optimal at 98%. His afebrile
status indicates that the fever has resolved. These
findings suggest that the patient is stable, though the
low platelet count remains a concern.

D. Physical Examination

Date Organ Method Normal Actual Interpreta

Assessed Findings Findings tion &
Analysis

10/09 Skin Inspection Skin warm, Skin warm, Normal

/24 dry, dry, skin
intact, intact, integrity
no rashes no rashes despite
or or risk
lesions lesions for
bleeding

Head and Inspection Symmetrica Symmetrica Normal, no

Scalp and l, l, abnormalit
Palpation no no ies
deformitie deformitie found
s, s,
scalp scalp
clean clean

Eyes Inspection Conjunctiv Conjunctiv Normal

a a vision and
pink, pink, ocular
sclera sclera function
white, white,
PERRLA PERRLA

Ears Inspection Symmetrica Symmetrica Normal, no

l, l, infections
no no or
discharge, discharge, lesions
external external noted
ear ear
without without
lesions lesions

Nose Inspection Nasal Clear Abnormal.

passages discharge It
clear, no with mild suggests
discharge, erythema possible
 no nasal of nasal co-
flaring mucosa infection
or
irritation
from
systemic
inflammati
on.

Mouth Inspection Oral Oral Normal, no

and mucosa mucosa signs of
Throat pink, no pink, no infection
lesions, lesions, or
tonsils tonsils inflammati
not not on
enlarged enlarged

Neck Inspection Full range Full range Normal, no

and of motion, of motion, signs of
Palpation no no lymphadeno
swelling, swelling, pathy
lymph lymph
nodes nodes
non- non-
palpable palpable

Chest Inspection Clear Clear Normal

and and breath breath lung
Lungs Auscultati sounds, sounds, function,
on symmetrica symmetrica no
l l adventitio
chest rise chest rise us
sounds
detected

Heart Auscultati Regular Regular Normal

on rhythm, no rhythm, no cardiac
murmurs murmurs function,
no
abnormalit
ies
noted
Table 1.5 Physical Examination Table
Discussion:

The physical examination of the patient reveals generally

normal findings across most systems, except for the nasal
assessment, which shows clear discharge and mild erythema of the
nasal mucosa. This abnormal finding may suggest a possible co-
infection or irritation secondary to systemic inflammation
associated with dengue fever. The rest of the integumentary,
head, scalp, eyes, ears, mouth, and throat examinations remain
within normal limits, with no signs of structural or functional
abnormalities. Similarly, the chest, lungs, and heart
assessments demonstrate normal respiratory and cardiac function,
with symmetrical movements and clear auscultation findings.

This single abnormal finding in the nasal mucosa

underscores the need for vigilant monitoring for potential
secondary infections or complications in dengue fever patients.
While the overall examination supports effective initial
management and stability, the noted nasal abnormality may
warrant further evaluation and supportive care to prevent
additional complications. Regular assessments remain critical in
detecting subtle changes that could indicate disease progression
or new issues requiring intervention.
CHAPTER II. CASE DISCUSSION AND PRESENTATIONS
CASE DISCUSSION
Dengue fever is an acute viral infection caused by the
dengue virus, which is transmitted through the bite of Aedes
mosquitoes. It manifests with flu-like symptoms and, in severe
cases, can progress to dengue hemorrhagic fever (DHF) or dengue
shock syndrome (DSS), both of which can be fatal without prompt
treatment. The World Health Organization (WHO) classifies dengue
into two major categories: dengue with warning signs and severe
dengue, which is characterized by plasma leakage, severe
bleeding, and organ impairment (Murray, 2017).

In this case, CTM, a 5-year-old male, presents with dengue

fever with warning signs, as evidenced by his low platelet count
and abdominal pain. The management of such cases requires close
monitoring of platelet counts, vital signs, and symptoms to
prevent the progression to severe dengue. Supportive treatment,
including fluid replacement, antipyretics, and careful
monitoring, is crucial for recovery (Murray, 2017).

REVIEW OF ANATOMY AND PHYSIOLOGY

Dengue fever affects multiple systems in the body, including the
immune system, the circulatory system, and the liver.

Immune System: The immune response to

the dengue virus includes the release
of cytokines and other immune
mediators, which can cause plasma
leakage, leading to vascular
permeability and hypovolemic shock in
severe cases (Ganong, 2020).

Figure 2.1 Immune System

Circulatory System: The vascular endothelium becomes permeable
due to the immune response, leading to plasma leakage, which
 causes hemoconcentration, low
blood pressure, and eventually
shock if untreated (Tortora &
Derrickson, 2019).

Figure 2.2 Circulatory System

Figure 2.3 Liver

Liver: The liver is often affected by dengue, leading to mild
to severe liver inflammation. This contributes to the production
of clotting factors, affecting the blood's ability to clot and
exacerbating the risk of bleeding due to thrombocytopenia
(Tortora & Derrickson, 2019).
PATHOPHYSIOLOGY
BOOK-BASED PATHOPHYSIOLOGY

Figure 2.4. Book-Based Pathophysiology of Dengue Fever

Reference: US Centers for Disease Control and Prevention
(2024)
CLIENT-BASED PATHOPHYSIOLOGY
 Figure 2.5 Client-Based Pathophysiology (Patient CTM)

CLINICAL MANIFESTATIONS
BOOK-BASED CLINICAL MANIFESTATIONS
● High fever
● Severe headache
● Retro-orbital pain
● Severe muscle and joint pain ("breakbone fever")
● Nausea and vomiting
● Abdominal pain
● Rash
● Bleeding tendencies, such as nosebleeds, gum bleeding, or
easy bruising
● Thrombocytopenia (Murray, 2017).
CLIENT-BASED CLINICAL MANIFESTATIONS
● Fever (4 days before admission)
● Abdominal pain
● Low platelet count (25)
● Jolly behavior upon admission
● No fever or visible signs of bleeding during the
hospitalization.
RISK FACTORS
BOOK-BASED RISK FACTORS
● Geographic Location: Dengue is endemic in tropical and
subtropical areas (WHO, 2019).
● Previous Dengue Infection: Having had a previous dengue
infection increases the risk of severe disease upon
reinfection due to antibody-dependent enhancement (WHO,
2019).
● Age: Younger children are more susceptible to severe dengue
(WHO, 2019).
● Weakened Immune System: Individuals with compromised
immune systems are at higher risk (WHO, 2019).
CLIENT-BASED RISK FACTORS
● Location: CTM lives in Cabanatuan City, Nueva Ecija, a
dengue-endemic region.
● Age: As a 5-year-old, CTM is at higher risk for severe
dengue compared to adults.
● Possible exposure: No history of previous dengue infection,
but residing in a mosquito-prone area puts him at risk for
contracting the disease.

PREVENTIONS
BOOK-BASED PREVENTIONS
● Mosquito Control: Use of insect repellent, window screens,
and bed nets to prevent mosquito bites (WHO, 2020).
● Environmental Control: Eliminate standing water where
mosquitoes breed (WHO, 2020).
● Vaccination: Dengue vaccines are available in some
countries for people who have had a previous infection
(WHO, 2020).
● Education: Raising awareness of dengue prevention methods
in endemic areas (WHO, 2020).
CLIENT-BASED PREVENTIONS
● Mosquito Protection: CTM’s family should ensure the use of
insect repellents and maintain a mosquito-free environment
at home.
● Family Education: CTM’s parents need to be educated about
the signs of dengue and preventive measures to protect both
CTM and his younger sibling.

COMPLICATIONS
BOOK-BASED COMPLICATIONS
● Dengue Hemorrhagic Fever (DHF): Characterized by increased
vascular permeability, thrombocytopenia, and hemorrhagic
manifestations (WHO, 2019).
● Dengue Shock Syndrome (DSS): A severe form of dengue where
plasma leakage leads to circulatory collapse and shock
(WHO, 2019).
● Organ Impairment: Severe cases may lead to liver, heart,
or neurological dysfunction (WHO, 2019).
CLIENT-BASED COMPLICATIONS
● Risk for Bleeding: CTM’s low platelet count puts him at
risk for bleeding, a common complication of dengue fever.
 LABORATORY FINDINGS

Laboratory Normal Actual Clinical Nursing

Examination Values Result Interpretation Responsibilities

Platelet 150- 25 Critically low Monitor vital

Count 450 x10^3/ platelet count, signs and assess
x10^3/ mm^3 indicating for signs of
mm^3 thrombocytopenia bleeding;
and increased educate family
risk for on precautions
bleeding (WHO, to prevent
2020). injury.

White Blood 4.0- 3.53 x Mild leukopenia, Monitor for

Cell Count 10.0 10 g/L consistent with signs of
x10 viral infection, infection;
g/L indicating the maintain hand
immune response hygiene and
is active infection
(Murray, 2017) control
practices.

Lymphocytes 0.20 - 0.46 Normal.

0.50

Monocytes 0.03 - 0.06 Normal.

0.10

Segmenters 0.40 - 0.48 Normal.

0.70

Red Blood 3.8 - 4.54 Normal.

Cell Count 5.8 x
10/L

Hemoglobin 110 - 126 Normal.

165
g/L

MCHC 320 - 344 Normal.

360
g/L

MCH 26.5 - 27.8 Normal.

55.5
pg

MCV 80-99 80.7 Normal.

fL

Hematocrit 0.35 - 0.37 Normal.

 0.50

Prothrombin 11-16 14.6 Normal.

Time (PT) sec sec

Internation 0.7 - 1.28 Normal.

Normalized 1.30
Ratio (INR)

Activated 30 - 33.4 Normal

Partial 40 sec sec
Thromboplas
tin Time
Table 2.1. Laboratory Findings Table
Discussion:

The laboratory findings revealed that CTM has a critically

low platelet count of 25 x10³/mm³, significantly increasing his
risk for bleeding—a common complication in dengue fever with
warning signs. His white blood cell count is slightly decreased
(3.53 x10⁹/L), consistent with viral infections, while his
hematological parameters, such as hemoglobin (126 g/L) and
hematocrit (0.37), are within normal limits, suggesting adequate
oxygen-carrying capacity and hydration. Coagulation profiles,
including Prothrombin Time (14.6 seconds) and Activated Partial
Thromboplastin Time (33.4 seconds), are within normal ranges,
indicating no significant clotting impairment. These findings
necessitate vigilant monitoring and preventive measures to
minimize the risk of bleeding.

The nursing focus should prioritize interventions to

address thrombocytopenia and its complications. Continuous
monitoring for signs of bleeding, such as petechiae or epistaxis,
is crucial, alongside maintaining hydration with intravenous
fluids to support vascular stability. Educating CTM’s caregivers
on bleeding precautions and recognizing warning signs is equally
vital to ensure timely interventions and prevent the progression
to severe dengue complications.
MEDICAL MANAGEMENT
BOOK-BASED MEDICAL MANAGEMENT
● Fluid Management
○ IV Fluids: Administration of intravenous fluids to
maintain hydration and replace lost fluids due to
plasma leakage is crucial. The choice of fluids (e.g.,
isotonic saline) should be guided by clinical status
and lab results (Murray, 2017).
○ Oral Hydration: For patients with mild symptoms, oral
rehydration solutions can be used to maintain fluid
balance (Murray, 2017).
● Monitoring
○ Regular monitoring of vital signs, hematocrit levels,
and platelet counts is essential to detect any signs
of complications such as bleeding or shock (Johnson,
2021).
○ Careful observation for warning signs of severe
dengue, including abdominal pain, persistent
vomiting, or bleeding (Johnson, 2021).
● Medications
○ Antipyretics: Paracetamol (acetaminophen) is
typically used to manage fever and pain. Aspirin and
non-steroidal anti-inflammatory drugs (NSAIDs) should
be avoided due to the risk of bleeding (WHO, 2019).
○ Antibiotics: These may be considered if there is a
suspicion of secondary bacterial infections,
particularly in cases with severe symptoms or low
immunity (WHO, 2019).
● Blood Transfusion: In cases of severe thrombocytopenia with
active bleeding or risk of bleeding, platelet transfusions
may be considered to stabilize the patient (Johnson, 2021).
● Patient Education: Educating the patient and family about
the signs of complications and the importance of seeking
immediate medical care if symptoms worsen (Johnson, 2021).
CLIENT-BASED MEDICAL MANAGEMENT
● Fluid Management:
○ IV Fluids: CTM is receiving intravenous fluids of
D5LRS at a rate of 20-21 gtts/min to ensure adequate
hydration and to replace fluid losses.
○ Oral Hydration: When tolerated, CTM is encouraged to
drink clear fluids, such as oral rehydration
solution, to maintain hydration status.
● Monitoring:
○ Vital signs are monitored every 4 hours, including
blood pressure, heart rate, and respiratory rate, to
detect any early signs of shock.
○ Daily lab tests are performed to monitor platelet
counts and hematocrit levels, with adjustments to the
management plan made as necessary based on results.
● Medications:
○ Antipyretics: CTM is receiving paracetamol 230 mg IV
every 4 hours as needed to manage fever and
discomfort.
○ Antihistamine: Ranitidine 23 mg every 12 hours was
prescribed to prevent gastrointestinal discomfort. 5
mL of Cetirizine every 12 hours is to alleviate
allergic reactions.
○ Vitamins: Vitamins C + Zinc are prescribed to support
immune function and help in tissue repair
○ Vasoconstrictor: Xylometazoline is used to relieve
nasal congestion and relieve symptoms.
● Patient Education:
○ The family has been educated about the disease,
including recognizing warning signs of severe dengue,
the importance of hydration, and when to seek further
medical attention.
 DRUG STUDY
Date Name of Mechanism Indication Contraindication Side Medication Nursing
the Drug of Action Effects Card Responsibilities

10/09 A. Generic Class: Indicated Hypersensitivity Nausea Before

/24 Name: Second- for the to cefuroxime or Administration:
Cefuroxime Generation treatment other Verify the
Cephalospor of cephalosporins; patient’s allergy;
B. Brand in Infections history of confirm the order
Name: Antibiotic caused by severe allergic and dosage; assess
Zoltax susceptibl reactions to baseline renal
Inhibits e penicillins may function.
C. Dosage: bacterial bacteria, indicate a
750 mg q12 cell wall including higher risk of During
synthesis, respirator cross- Administration:
D. Route leading to y tract reactivity. Monitor the IV site
IV cell lysis infections for redness,
and death. and skin swelling, or
infections infiltration;
, observe for
particular immediate
ly in hypersensitivity
cases of reactions.
secondary
infection After
during Administration:
dengue Assess for delayed
fever. allergic reactions;
reinforce adherence
to full course
antibiotics;
 document the time
and route of
administration.

Table 2.2 Cefuroxime

 DRUG STUDY
Date Name of Mechanism Indication Contraindication Side Medication Nursing
the Drug of Action Effects Card Responsibilities

10/09 A. Generic Class: Indicated Hypersensitivity None Before

/24 Name: Histamine for the to ranitidine or Administration:
Ranitidine H2-Receptor treatment any component of Assess for
Antagonist of the formulation; contraindications;
B. Brand duodenal caution in review the
Name: Decreases ulcers, patients with patient’s current
Zantac gastric gastric renal medications;
acid ulcers, impairment. verify the timing
C. Dosage: secretion and of the dose.
23 mg q12 by gastroesop
blocking hageal During
D. Route the reflux Administration:
IV action of disease Administer with or
histamine (GERD), without food,
on and as per physician’s
H2 to prevent orders; observe for
receptors stress signs of allergic
in the ulceration reactions; monitor
gastric in for immediate
parietal critically relief
Cells. ill or adverse effects.
patients.
After
Administration:
Assess the
patient’s
response to
 medication;
document the
patient’s
symptoms and any
side effects.

Table 2.3 Ranitidine

 DRUG STUDY
Date Name of Mechanism Indication Contraindication Side Medication Nursing
the Drug of Action Effects Card Responsibilities

10/09 A. Generic Class: Indicated Severe hepatic Nausea Before

/24 Name: Analgesic for the impairment or Administration:
Paracetamo and relief of active liver Check the patient’s
l Antipyretic mild to disease; baseline temp and
moderate hypersensitivity pain level; review
B. Brand Inhibits pain and to paracetamol. the patient’s liver
Name: the for the function; verify
Tamin synthesis reduction the prescribed dose
of of fever. and frequency.
C. Dosage: prostagland
230 mg q4 ins in the During
PRN central Administration:
nervous Monitor for signs
D. Route: system, of allergic
IV reducing reactions or
pain and unusual symptoms;
fever. Record the dose,
route, and time of
administration.

After
Administration:
Document the
patient’s response
to the medication;
encourage hydration
to help medication
 metabolism.

Table 2.4 Paracetamol

 DRUG STUDY
Date Name of Mechanism Indication Contraindication Side Medication Nursing
the Drug of Action Effects Card Responsibilities

10/09 A. Generic Class: Indicated Hypersensitivity Drowsine Before

/24 Name: Second- for the to cetirizine or ss Administration:
Cetirizine Generation relief of hydroxyzine; Assess the
Antihistami allergy caution in patient’s allergy
B. Brand ne symptoms, patients with symptoms and
Name: such as severe renal history of drug
Allerkid Selectively sneezing, impairment. allergies; verify
inhibits runny renal function;
C. Dosage: peripheral nose, confirm the
5 mL H1 and prescribed dose
(syrup) receptors, itching, and frequency.
q12 providing as well as
relief from for During
D. Route: allergic chronic Administration:
PO symptoms urticaria. Observe for
without immediate effects;
significant record the dose
sedation. and administration
time.

After
Administration:
Monitor for
delayed allergic
reactions or
adverse effects;
document the
 patient’s response
and side effects;
encourage
hydration to help
clear the
medication.

Table 2.5 Cetirizine

 DRUG STUDY
Date Name of Mechanism Indication Contraindication Side Medication Nursing
the Drug of Action Effects Card Responsibilities

10/09 A. Generic Class: Indicated Hypersensitivity None Before

/24 Name: Antioxidant for the to any Administration:
Vitamin C support of component; Confirm the
and Zinc Supports immune excessive patient’s need for
immune function vitamin C can supplementation;
B. Brand function, and to lead to check for
Name: is potentiall gastrointestinal contraindications;
Ceelin essential y reduce upset. ensure it is given
Plus for immune the with food.
cell duration
C. Dosage: function, of colds During
5 mL and has and Administration:
(syrup) OD anti- respirator Administer with a
inflammator y full glass of
D. Route: y infections water; observe for
PO properties. . immediate
reactions;
monitor the
patient’s tolerance
to the supplement.

After
Administration:
Monitor the patient
for signs of
overdose; document
the patient’s
 response and any
side effects.

Table 2.6 Vitamin C + Zinc

 DRUG STUDY
Date Name of Mechanism Indication Contraindication Side Medication Nursing
the Drug of Action Effects Card Responsibilities

10/09 A. Generic Class: Indicated Hypersensitivity None Before

/24 Name: Topical for the to Administration:
Xylometazo Vasoconstri temporary xylometazoline; Assess the
line ctor relief of not recommended patient’s nasal
nasal for patients congestion and
B. Brand Reduces congestion with severe symptoms; verify
Name: nasal associated hypertension or the dose and
Drixine congestion with cardiovascular duration of use;
by colds, disorder. encourage the
C. Dosage: constrictin allergies, patient to blow
TID g blood and their nose gently.
vessels in sinusitis.
D. Route: the nasal During
Nasal mucosa. Administration:
Administer the
spray while
instructing the
patient to tilt
their head slightly
forward; avoid
contamination by
keeping the spray
tip clean; record
the time and dose
administered.

After
 Administration:
Assess the
effectiveness in
relieving nasal
congestion; monitor
for rebound
congestion or
systemic effects;
advise on proper
use to prevent
overuse or
complications.

Table 2.7 Xylometazoline

CHAPTER III. NURSING MANAGEMENT
PROBLEM IDENTIFICATION, ANALYSIS, AND PRIORITIZATION

Nursing Type and Rank Justification

Diagnosis/Cues

Acute Pain related Type: Actual The patient has

to abdominal Rank: 1 reported abdominal
discomfort pain, which may
indicate disease
progression or
complications
associated with
dengue. This
requires prompt pain
management and
monitoring.

Impaired Comfort Type: Actual Nasal congestion in

related to nasal Rank: 2 dengue fever can
congestion secondary cause discomfort due
to dengue fever to difficulty
breathing and
irritation, as
evidenced by the
patient’s runny nose
and reported
discomfort.
Addressing this
discomfort is
essential to improve
the patient’s
comfort.

Risk for Bleeding Type: Risk/Potential Thrombocytopenia

related to low Rank: 3 significantly
platelet count. increases the risk
for bleeding,
especially with
dengue fever. The
critical platelet
count necessitates
close monitoring and
preventive measures.
Table 3.1. Problem Identification, Analysis, and
Prioritization
 NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

ive Data: Subjective Data: Acute Pain Short-Term Independent: Independent: Short-Term Goal:
Masakit po “Masakit po ang related to Goal: 1. Assess pain CTM reported a
tiyan ko.” abdominal CTM will levels regularly 1. Consistent reduction in
discomfort report a using a assessment allows pain to a
secondary to reduction in standardized pain for appropriate manageable level
Objective Data: dengue fever pain to a scale. adjustments in of 3/10 within 4
- Vital Signs: as evidenced manageable pain management hours of
October 9, 2024: by abdominal level (3/10) 2. Use non- strategies based initiating pain
BP: 90/60 mmHg, pain is rated or lower pharmacological on CTM's reported management
PR: 109 BPM, 6/10 on the within 4 hours methods such as pain levels. interventions.
RR: 26 BPM, pain scale in of initiating positioning the
the epigastric pain patient in a semi- 2. Non-
SpO2: 98%
Fowler's position pharmacological Long Term Goal:
Pain Scale: 6/10 region. management
(head elevated at interventions can CTM does not
interventions.
30–45 degrees) effectively reduce experience pain
- Physical pain perception
Examination: Long-Term with a pillow by the time of
Goal: under the knees to and enhance discharge.
Abdominal pain comfort in
CTM will no relieve abdominal
in the children
longer tension and
epigastric experience improve comfort. The goal was
region upon pain by the Dependent: met.
palpation. time of
Dependent:
discharge. Paracetamol is an
Administer
effective
 prescribed analgesic for
Paracetamol 230 managing mild to
mg, q4, PRN as moderate pain,
needed for pain helping to improve
management. CTM's comfort and
promote healing.
Collaborative:
Work with the Collaborative:
healthcare
provider to Collaboration with
evaluate the the healthcare
effectiveness of team ensures that
pain management CTM receives a
strategies and comprehensive
consider approach to pain
adjustments if management,
pain is not incorporating
controlled. feedback from
multiple
disciplines.

Table 3.2 Nursing Care Plan 1

 NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: Impaired Short-Term Independent: Independent Short-Term Goal:

“Kuya, hindi Comfort Goal: 1. Ensure adequate 1. Proper The patient
komportable ang related to The patient hydration to help hydration helps reports improved
pakiramdam ko sa nasal will report thin mucus and improve mucus comfort and
ilong ko po may congestion improved improve nasal clearance, relief from
sipon na tulo secondary to comfort and drainage prevents nasal congestion
nang tulo.” dengue fever relief from 2. Educate the dehydration, and within 8 hours.
as evidenced nasal patient on proper supports the
Objective Data: by a runny congestion hygiene techniques body’s natural The goal was
- Vital Signs: nose and within 8 3. Encourage the healing process met.
BP: 90/60 mmHg; patient hours. use of warm during illness.
PR: 109 BPM; reports of compress or steam 2. Minimizes the Long-Term Goal:
RR: 26 BPM; discomfort. Long-Term inhalation risk of infection The patient
SpO2: 98% Goal: and prevents reports complete
Physical The patient Dependent: worsening of nasal resolution of
Examination: will 1. Administer congestion or nasal congestion
The patient’s experience Cefuroxime 750mg discomfort. and no
nose has a clear complete q12, IV as 3. Warm compress discomfort by
discharge with resolution of prescribed by the or steam the time of
mild erythema of nasal physician. inhalation can discharge.
nasal mucosa congestion by 2. Administer help loosen thick
Laboratory the time they Xylometazoline mucus and soothe The goal was
examination: are TID, nasally as inflamed nasal met.
WBC: 3.53 x 10 discharged, prescribed by the tissues.
g/L with no physician.
reports of 3. Administer Dependent
discomfort Cetirizine 5ml, 1. Administering
related to q12, PO as antibiotics ensures
Assessment Diagnosis Planning Intervention Rationale Evaluation

nasal prescribed by the the elimination of

blockage. physician. bacterial infection
and prevents
Collaborative: complications.
2. Nasal
Assist with
decongestant
laboratory relieves congestion,
examinations, improving airway
including CBC to patency and patient
check for WBC. comfort.
3. Antihistamine
reduces allergy-
related symptoms,
promoting
respiratory ease and
comfort.

Collaborative
Monitoring WBC is
critical
information for
diagnosing, and
managing various
medical conditions
effectively.
Table 3.4. Nursing Care Plan Table 2
 NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective Data: Risk for Short-Term Independent: Independent: Short-Term Goal:

- Vital Signs: Bleeding Goal: 1. Monitor vital 1. Regular The parents were
BP: 90/60 mmHg; related to low The parents signs and assess monitoring allows able to show an
PR: 109 BPM; platelet count will show an for signs of for early understanding of
RR: 26 BPM; understanding bleeding every 4 detection of bleeding
SpO2: 98% of bleeding hours. changes in the precautions
- Lab Findings: precautions 2. Educate the patient’s within 8 hours.
Low platelet within 8 family and patient condition that
count of 25,000 hours. on safety could indicate The goal was
per microliter precautions to bleeding met.
Long-Term prevent injuries. complications,
Goal: 3. Encourage the enabling timely Long-Term Goal:
The patient’s use of soft interventions. The patient’s
platelet count toothbrushes and 2. Teaching the platelet count
will increase avoid sharp family about increased to
to within objects. safety measures within normal
normal limits helps minimize the levels of
(150,000 - Dependent: risk of injury, 190,000 per mcL
450,000 per Administer IV which is crucial by the time of
mcL) by the fluids as given CTM’s low discharge.
time of prescribed by the platelet count and
discharge. physician. increased bleeding The goal was
risk. met.
Collaborative: 3. To minimize the
Assist with risk of mucosal
laboratory trauma and
examinations, accidental cuts,
including CBC to which can lead to
 check the bleeding.
patient’s platelet
count. Dependent:
Maintaining
hydration with IV
fluids supports
circulatory
stability,
reducing
hemoconcentration,
and vascular
complications.

Collaborative:
Monitoring
platelet count and
coagulation
parameters
provides important
information about
the patient’s
hemostatic status.
Table 3.3. Nursing Care Plan Table 3
DISCHARGE PLANNING
MEDICATION

Name of Dosage & Route Time Curative Side

Drug Frequency Effects Effects

Paraceta 230 mg Oral During Reduces Nausea,

mol q4 PRN fever fever rash
episodes and (rare),
, at alleviat liver
least 4 es mild toxicity
hours pain if
apart overdose
d

Vitamin 5 mL OD Oral Morning, Boosts Mild

C + Zinc after immune stomach
meals system upset,
and diarrhea
helps in (with
recovery high
doses)
Table 3.5 Discharge Medications

ENVIRONMENT/EXERCISES

Type of Procedure/ Use of Restriction Rationale

Environment Steps Equipment
/Activity

Suitable Ensure the Mosquito Avoid Provides a

Environment child’s net and fan exposure to safe,
room is (if needed) excessive comfortable
quiet, noise or space for
clean, and bright rest and
well- lights. recovery,
ventilated; reduces the
use risk of
mosquito infection,
nets/screen and
s; keep the promotes
space relaxation.
clutter-
free;
maintain a
comfortable
temperature
. Ensure
the
environment
 is free
from
mosquito
breeding
sites.

Light Encourage None Avoid Improves

Walking short walks running or circulation
for 5-10 strenuous , prevent
minutes, 2- activities. muscle
3 times a stiffness,
day, or as and support
tolerated. gradual
recovery of
strength.

Hydration Encourage Cup or Limit Maintains

Routine frequent bottle sugary or hydration,
small sips carbonated prevents
of fluids beverages dehydration
throughout , and
the day supports
faster
recovery of
bodily
functions.

Stretching Gently None Avoid Improves

extend and overexertio flexibility
flex arms n or , prevents
and legs prolonged stiffness,
while sessions and
seated or promotes
lying down. relaxation.
Table 3.6 Environment/Exercises

TREATMENT

Name of Treatment Indication/Purpose Nursing

Responsibilities

Multivitamins To enhance immune Encourage adherence

recovery and to daily dosing;
support overall highlight the
nutritional status benefits of
post-illness. vitamins in
supporting the
immune system.

Hydration To ensure ongoing Advise the parents

Maintenance hydration. to offer regular
sips of clear
fluids; educate the
parents on signs of
dehydration (dry
lips, nausea, dark
yellow or brown
urine)
Table 3.7 Treatment

OUTPATIENT

Date of Return Time Place Physician

October 24, 8:00 am ELJ Hospital Marlon Jay F.

2024 Lopez, MD
Table 3.8 Outpatient

DIET

Meal Serving Rationale

Breakfast Lugaw (rice 1 cup of Easily

porridge) with porridge, 1 digestible and
malunggay boiled egg and energy-rich,
leaves and a a splash of lugaw provides
boiled egg malunggay carbohydrates,
leaves while
malunggay and
eggs add
protein and
iron to
support
recovery.

Snack Pandesal and 2-3 pieces and A source of

Calamansi 300 ml of carbohydrates
Juice calamansi to maintain
juice energy level
and High in
vitamin C, it
supports the
immune system
and aids in
hydration

Lunch Tinolang manok 1 piece of nutritious and

and rice small boneless comforting,
 chicken part offering
and 1 cup of protein,
soup vitamins, and
1 cup of rice minerals for
recovery while
rice provide
carbohydrates

Snack Boiled Camote 1-2 pieces Provides

and Buko juice 300 ml energy and is
fiber-rich and
Rehydrates and
replenishes
electrolytes
naturally.

Dinner Sinigang na 1-2 cups Fish provides

bangus with 1 cup of rice protein and
veggies and omega-3 fatty
rice acids, while
malunggay and
papaya support
immune health
while rice is
carbohydrate
source
Table 3.9 Diet
 HEALTH TEACHING PLAN

Objectives Content Method of Time Resources Methods of

Instruction Allocated Evaluation

1. - What Talk: 15-20 -Visual - Talk and

Cognitive: is Briefly minutes aids: Show: Use
Caregivers dengue explain Pictures easy-to-
will fever? A dengue of understand
understand mosquit fever and dengue language
dengue o-borne its symptoms and
fever, its illness management and practical
symptoms, common in simple preventi demonstrati
and in terms. on ons.
warning tropica - Show: steps.
signs. l Demonstrate -
2. areas. mixing ORS, Mosquito
Affective: - using repellen
Caregivers Symptoms mosquito t,
will feel and repellents, mosquito
motivated warning and net, and
signs:
to covering a water
implement Fever, water containe
preventive abdomin containers. r with a
measures al - lid.
and pain, Interactive
closely vomitin : Allow
monitor g, caregivers
the bleedin to ask
child’s g, and questions
condition. drowsin and
3. ess. practice
Psychomotor - what is
: Preventi taught.
on:
Caregivers
will Elimina
practice te
preparing stagnan
ORS and t
demonstrat water,
e mosquito use
control repelle
measures. nts,
dress
the
child
in long
sleeves
, and
sleep
under a
mosquit
o net.
-
Hydratio
n: Give
the
child
fluids
to
prevent
dehydra
tion.
- When
to go to
the
hospital
:
Persist
ent
vomitin
g,
severe
abdomin
al
pain,
or
signs
of
bleedin
g.
Table 3.10 Health Teaching Plan
 BIBLIOGRAPHY

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Tortora, G. J., & Derrickson, B. (2019). Principles of Anatomy

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Ganong, W. F. (2020). Review of Medical Physiology (26th ed.).

McGraw-Hill.

Johnson, B. W. (2021). Clinical Practice Guidelines for Dengue

Fever: Diagnosis and Management. In Infectious Diseases
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Centers for Disease Control and Prevention. (2023). Dengue.

Retrieved from https://www.cdc.gov/dengue/index.html

WHO (World Health Organization). (2019). Dengue Guidelines for

Diagnosis, Treatment, Prevention and Control. Retrieved

from https://www.who.int/publications/i/item/9789241547871

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Control. Retrieved from https://doh.gov.ph/dengue

National Center for Biotechnology Information. (2020). Dengue

 Virus: Epidemiology, Diagnosis, and Treatment. Retrieved
from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7453354/

Ranjan, R., & Ghosh, P. (2022). Management of Dengue Fever in

Children: A Review. Journal of Pediatric Infectious

Diseases, 17(2), 45-51. Retrieved from
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