Dengue fever for nurses

Dengue Fever for nurses, includes phases of dengue fever, types of dengue fever, nursing care plan , and health education

1. Dengue Fever = Semester 4 (Cohort 1/16) = by: Ms.Kong Mun Yi CTM 1/17 International Medical University

2. Learning Outcomes At the end of this lesson, the students will be able to: 1 . Define dengue fever 2. State the pathophysiology of dengue fever 3. Describe the clinical manifestation of dengue fever . 4 . State the assessment, diagnostic test of patients with dengue fever.

3. 5. Explain the management of patients with dengue fever . 6 . State the complications of dengue fever. 7 . Discuss the nursing diagnosis and nursing interventions of patients with dengue fever. 8. Recognize the importance of proper management of patients with dengue fever.

4. What is arthropod? no internal spine joined segments, and a hard covering, like a shell. have an exoskeleton “ Arthropoda ”, in Latin, means "those with joint feet.“

5. Arboviral (Arthropod-borne Viral) Diseases = infections caused by a group of viruses spread to people by the bite of infected arthropods (insects ). such as mosquitoes and ticks. I nfected mosquitoes are the most common type of arthropods that spread diseases.

6. Dengue Fever an arthropod-borne viral diseases ( mosquito borne ) in tropical & subtropical regions. by infected female : - Aedes A egypti - Aedes Albopictus breed in the urban & semi urban areas.

7. Dengue Fever Virus There are 4 distinct, but closely related, serotypes of the virus that cause dengue ( DENV-1, DENV-2 , DENV-3 and DENV-4 ). single-stranded RNA viruses that belong to the family Flaviviridae and the genus Flavivirus - a family which includes other relates vector-borne viruses (e.g., West Nile virus, Yellow Fever virus, Japanese Encephalitis virus)

8. Incidence Of these, 500,000 cases develop into dengue haemorrhagic fever, which results in up to 25,000 deaths annually worldwide .

9. Incidence

10. Mode of Transmission

11. Mode of Transmission Aedes aegypti is a day-time feeder; - early morning and evening before dusk. Female Aedes aegypti bites multiple people during each feeding period . Can also transfer the virus to infect its eggs. K nown to be transmitted via occupational exposure to infected blood (e.g. needle stick injury, blood splashed in eyes).

12. Epidemiology of Dengue Fever predominantly an urban disease due to close proximity in high densities of susceptible hosts (human). inadequate basic urban infrastructure – unreliable water supply ( e.g. store water in containers close to homes ) ↑ solid waste discarded which provide larval habitats in urban areas.

13. Pathophysiology of dengue fever I ncubation period for dengue infection is 4–7 days . M ay be asymptomatic or from mild febrile to severe, with / without plasma leakage and organ impairment. After the incubation period, the illness begins and followed by three phases: i . febrile ii . critical iii . recovery phase

14. Stages of dengue fever

15. i . Febrile Phase - Sudden high grade fever (> 39°C ) usually last 2-7 days. ~ rashes, myalgia, arthralgia, headache, retro-orbital pain ~ Anorexia, nausea & vomiting - Mild hemorrhagic manifestations: ~ petechiae & mucosal bleeding ~ Positive Tourniquet test - Full Blood Count - progressive ↓ in WBCC & Platelet Count (should alert the suspicion of dengue infection)

16. i . Febrile Phase Petechiae rashes Mucosal bleeding

17. ii . Critical Phase - occurs after 3rd to 5th day of fever, lasts about 24 – 48 hrs. - rapid ↓ in body temperature . - O nset of plasma leak into the pleural & abdominal cavities, intravascular fluid depletion. - severe plasma leakage may lead to hemorrhagic shock . - Organ dysfunctions such as hepatitis, encephalitis & myocarditis may occur during this phase

18. Reduced in: Platelet < 100,000/mm³ (thrombocytopenia) WBC < 4,000 (Leucopenia) ~ viral infection Albumin < 33 g/L Increased in: AST > 40 U/L (enzyme released by liver) ↑ Haematocrit (early marker) - > 40% in female - > 46% in male - > 20% from HCT baseline Haemodynamic instability – ↓ BP Fluid accumulation in interstitial space ( eg : pleural effusion,ascites ) ~ late marker ii . Critical Phase Evidence of plasma leakage: Other lab results:

19. Abdominal pain Persistent vomiting Restlessness with altered level of consciousness Hemodynamic instability: - prolonged capillary refill time (> 2 secs) - cool peripheries - tachycardia - weak pulse volume Mucosal bleed Tender / enlarged liver Ascites ii . Critical Phase Clinical warning signs with possibility of complications :

20. iii. Recovery/Reabsorption Phase - After 24 - 48 hours of critical phase plasma leakage stops – normal vascular permeability R eabsorption of extravascular fluid. general well being improve gastrointestinal symptoms improve haemodynamic status stabilises diuresis ensues - may have a classical rash of “isles of white in the sea of red” with generalised pruritus. Clinical signs:

21. iii. Recovery/Reabsorption Phase HCT level stabilizes - further ↓ due to dilutional effect ( haemodilution ) following reabsorption of extravascular fluid. WBC and Platelet starts to ↑. Lab tests:

22. Virology & Serology

23. Dengue Shock Syndrome

24. RECAP 1. The mode of dengue transmission is from: Infected human → mosquito (infected mosquito) ↓ Infected human ← uninfected human 2. Normal habitat for dengue mosquitoes are: i . sub tropical & tropical climate ii. clogged or stagnant water storage

25. Dengue fever infected patients are either asymptomatic or they have one of three clinical presentations: i . Undifferentiated Fever; ii. Dengue Fever with or without hemorrhage; or iii. Dengue Hemorrhagic Fever or Dengue Shock Syndrome.

26. Dengue fever Undifferentiated Fever benign fever with non-specific symptoms do not meet criteria for DF Normally young children or those experiencing their first infection, recover fully without hospitalization Dengue Fever with or without hemorrhage - Normally older children or adults

27. Dengue hemorrhagic fever mortality rate: treated ~ 2-5 % untreated ~ 50 % usually occurs if there is infection more than once. Symptoms: similar to dengue fever, may become severe. rapid deterioration 2-5 days after fever starts

28. Bleeding from gums or nose hematuria, melena or hemoptysis Bleeding under the skin Positive tourniquet test Difficult or rapid breathing Irritability or restlessness Hemodynamic instability Clinical manifestations: Dengue hemorrhagic fever

29. • progressive thrombocytopenia • ↑ hematocrit (20% absolute rise from baseline) • ↓ albumin (signs of hemoconcentration preceding shock) • ↑ (mildly) Transaminase level • ↑ AST Lab tests: Dengue hemorrhagic fever

30. Dengue Shock Syndrome (DSS ) - severest condition of dengue fever - characterized by: Severe abdominal pain Hemoptysis Altered level of consciousness Fluctuation in body temperature Hypotension

31. Risk Factors Dengue fever has a mortality rate of less than 1 %. When treated, DHF has a mortality rate of 2-5 %, but if left untreated, mortality rate is as high as 50 %. However , the figure can be minimized to 0.2 % in hospitals with staff trained in managing the disease.

32. Diagnostic tests 1. Tourniquet Test - helpful in febrile phase (< 3 days) - Method: i . Take the patient's BP & record it, for example, 100/70 . ii. Inflate the cuff to a point midway between SBP & DBP ex: ( 100 + 70 ) ÷ 2 = 85 mm Hg iii . Maintain pressure for 5 mins . iv . Count petechiae below antecubital fossa. Positive test: > 20 petechiae / square inch

33. Diagnostic tests 2. Non-Structural Protein- 1 (NS 1 Antigen) - Secretion of the NS 1 protein indicates viral infection. - The presence after day 5 predicts severe dengue. - Detection rate is much better in acute primary infection (75 %-97%)

34. Diagnostic tests 3. RNA test for dengue viral antigen (ELISA) i ) Dengue IgM test - higher in primary infections compared to secondary infections . - usually positive after day 5-7 of illness. - N egative IgM taken before day 5-7 of illness does not exclude dengue infection. - If dengue IgM is negative before day 7 , a repeat sample must be taken in recovery phase.

35. Diagnostic tests 3. RNA test for dengue viral antigen (ELISA) ii) Dengue IgG test - can be detected in patients after day 7 of onset of fever . - A repeat dengue IgG is recommended if dengue IgM is still negative after day 7 to confirm secondary dengue infection .

36. Diagnostic tests 4. Rapid Combo Test ( RCT) - Detect presence of dengue antigen and dengue IgM and IgG antibodies. Results within 15-20 minutes. Useful during the early phase of onset of fever. - The sensitivity is 94%.

37. Investigations for monitoring 1. White cell count (WCC) and Platelet count normal – in early febrile phase ↓ rapidly - as the disease progresses (due to ↓ of neutrophils) In recovery phase, the WCC normalises followed by platelet 2 . Haematocrit (HCT ) - ↑ (> 20 %) a marker of plasma leakage - normal are: ~ male – 42 to 46% ~ female – 40 - should be done on first visit in suspected dengue fever

38. Investigations for monitoring 3. Full Blood Count - Monitor Hb for signs of bleeding 4. Liver Function Test (LFT) ↓ albumin (due to loss of protein) ↑ Transaminase level - mildly ↑ AST & ALT (> 1,000 u/l ) 5 . Coagulation profile ↑ coagulation time (>14 seconds ) - Prothrombin time, Thrombin time, Partial thromboplastin time

39. Investigations for monitoring 6. Blood gases - Metabolic acidosis in prolonged shock 7 . Blood Urea Nitrogen - ↑ in the terminal stage of shock 8 . Chest X-ray - bilateral pleural effusion in shock due to plasma leakage. 9 . Ultrasound - pleural effusion, pericardial effusion, gallbladder wall oedema & intraperitoneal fluid collection

40. 1. What are 3 severities of dengue fever? i . Dengue fever – asymptomatic - symptomatic ii. Dengue hemorrhagic fever (DHF) iii. Dengue Shock Syndrome (DSS)

41. 2. Name the tests used to diagnose Dengue antigen in the body. i . IgM ii.IgG iii. NS1 Antigen iv. Rapid Combo test (RCT)

42. 3. Name the blood tests done to monitor for: - thrombocytopenia: platelet count – low - leucopenia: WBC – low - Dehydration and plasma leakage: HCT – High - Hemorrhage: Hb – low - Coagulation: PT , PTT - high

43. Management for dengue fever Medication - no specific medications for dengue fever - symptomatic & supportive treatment 1. Mild analgesic-antipyretics ( Acetaminophen-Tylenol, Paracetamol) ~ lethargy , malaise, and fever 2 . Oral Rehydrating Salt (ORS) ~ diarrhoea ~ in small amount for children.

44. Management for dengue fever Medication 3 . Sodium bicarbonate - to treat acidosis, if not treated, may lead to DIVC ( Disseminated intravascular Coagulation) AVOID - Aspirin - Nonsteroidal anti-inflammatory drugs (NSAIDs) - Corticosteroids

45. Management for dengue fever Fluid Management 1. Oral rehydration therapy - recommended for patients with moderate dehydration caused by high fever & vomiting. 2. IV fluids (0.9% saline or Ringer’s Lactate solution) - patients with increasing HCT & evidence of ongoing plasma leakage, despite increased oral intake. - patients who are vomiting, severe diarrhoea and not tolerating orally.

46. Management for dengue fever Fluid Management 3 . Blood transfusion and blood products. - blood transfusion for internal or gastrointestinal bleeding - fresh frozen plasma for patients with coagulopathy

47. 1. Vital signs: HR, Respiratory rate, T °, BP ~ tachypnea , acidotic breathing (rapid & deep) ~ hypotension 2. C apillary refill time (normal <2 seconds ) & skin colour 3. Mental state – GCS score, conscious level Evidence of bleeding I/O chart – hydration status, urine output B lood test results - early signs of DHF or shock. Assessments Nursing Interventions

48. 1. Monitor: i ) Blood pressure ii) Monitoring pain ~ location, increasing , diffused, or localized. iii) Vascular access ~ maintain patency for fluid administration or blood replacement iv ) Medication regimen ~ identify medications that might exacerbate bleeding problem 2. Fluid replacement. Establish 24-hour fluid replacement needs . Interventions Nursing Interventions

49. 6. Managing nose bleeds : ~ Elevate position of the patient ~ apply ice bag to the bridge of the nose and forehead . 7 . Trendelenburg position: ~ restore blood volume to the head 8 . Continuous monitoring of blood test results ~ inform doctor immediately for signs of impending shock. 9. Continuous monitoring of intake output chart ~ encourage patient to drink more water Interventions Nursing Interventions

50. Achieved the following: Displayed hemodynamic stability. Absence of signs of bleeding. Displayed laboratory results within normal range Maintained optimum fluid volume Reported pain is relieved or controlled. Demonstrated adequate tissue perfusion. Evaluation: Nursing Interventions

51. Complications of dengue - are rare, but may include the following: Cardiomyopathy Seizures , encephalopathy, and viral encephalitis Hepatic injury Pneumonia Pleural effusion Renal complications Death

52. Discharge and Home Care Guidelines • Avoid diuretics. ~ Avoid caffeine and alcohol, to reduce effects of diuresis. • Follow-up appointments. ~ Comply with the recommended medical and laboratory follow- ups. • Oral care. ~ use soft toothbrush to reduce risk of injury to the oral mucosa.

53. Discharge and Home Care Guidelines Diet . ~ Food rich in vitamin K to promote blood clotting. Education. ~ use of mosquito nets and repellents.

54. Prevention 1 . Prevent Aedes mosquitoes from breeding - Dispose all unwanted containers that can hold water ( eg ; cans, bottles). - Cover all water containers , add larvicides , as recommended. - Change water and scrub the insides of all water containers once a week

55. Prevention 2. Keep adult mosquitoes away ~ Using aerosol insect repellant (DEET) ~ Wear full sleeves clothes and long dresses ~ Use mosquito coils and electric vapour mats during the daytime ~ Use mosquito nets to protect children, old and weak people

56. Nursing diagnosis 1. Deficient Fluid Volume related to increased capillary permeability, bleeding , vomiting, and fever. Goal : Adequate fluid volume . 1 . Observation of vital signs at least every 4 hours. R : detect signs of hypovolemia, plasma leakage 2. Assess the general state and condition of the patient R: detect signs of hypovolemia 3 . Record and observe intake and output chart. R : Poor fluid intake and poor urine output indicates hypovolemia

57. Nursing diagnosis Cont : 4. Provide adequate hydration according to the needs of the body by encouraging patient to drink water or fruit juices at least 1.5 L/day. R: Ensure patient is well hydrated 5 . Monitor laboratory values: electrolyte / blood tests R : Early interventions can be taken if suspected hemorrhagic shock 6. Monitor and record the daily weight. R : Ensure patient is not losing too much body weight from dehydration 7 . Monitor the patency of intravenous fluids infusion R : Ensure that patient receives enough fluid.

58. 2 . Hyperthermia related to process of dengue virus infection. Goal : Body temperature returned to normal 1 . Observation of vital signs, especially temperature R : To monitor the trend of temperature. 2 . Give a cold compress (plain water) on the forehead and armpits . R: to avoid temperature from increasing. 3. Encourage to put on clothing that can absorb sweat like cotton. R : Patient feels comfortable Nursing diagnosis

59. Nursing diagnosis Cont : 4 . Encourage patient to drink more fluid. R: Increase hydration status from fever 5. Advise patient to reduce physical activities, rest on bed . R: reduce metabolism rate which can increase body T °. 6. Serve Acetaminophen (Tylenol ) or Paracetamol according to prescription . R: relief pain and fever .

60. 3 . Risk for bleeding related to low platelet count (thrombocytopenia ) Goal : Prevent excessive bleeding 1 . Assess and record: - vital signs (pulse, blood pressure, capillary refill) - circulation in the extremities (temperature, color) - Stools, PV Bleeding - Mucosal bleeding - Skin (hematoma, petechial) R: to detect early signs of hemorrhage Nursing diagnosis

61. Nursing diagnosis Cont : 2. Monitor blood tests results: - Platelet count - Coagulation time - HCT R : Status of thrombocytopenia is monitored and early interventions can be taken. 3 . Evaluate the patient’s use of any medications that can affect hemostasis ( e.g , anticoagulants, salicylates, NSAIDs ) R: Inform doctor to change prescription .

62. Nursing diagnosis Cont : 4 . Use a soft-bristled toothbrush and non- abrasive toothpaste. Avoid the use of toothpicks and dental floss . R : Reduce trauma to mucous membrane. 5 . Limit straining with bowel movements, forceful nose blowing , coughing , or sneezing. R : may cause trauma to the mucosal linings in rectum, nasal passages , or upper airways.

63. 4 . Imbalanced nutrition less than body r equirements related to nausea , vomiting, no appetite Goal : Patient increase in food intake. 1 . Encourage patient to eat in small amount, but frequent. R : Ensure patient has sufficient intake 2. Serve patient’s favourite food if possible. R : to improve of nutritional intake 3.Measure daily weight at the same time and with the same scale. R: monitor weight loss due to poor intake Nursing diagnosis

64. Nursing diagnosis Cont : 4 . Explain to the patient on importance of adequate intake for fast recovery R : encourage patient to have adequate intake 5. Give and help with oral hygiene. R : Increased appetite and oral input. 6. Avoid food that are gassy and oily R : Reduce distention and gastric irritation.

65. CLASSICAL SIGNS of DENGUE FEVER Headache Retro-orbital pain General body pain ( arthralgias , myalgias ) Positive Tourniquet test Mild hemorrhagic manifestations Sudden onset of high fever Leucopenia

66. WARNING SIGNS 1. Raised HCT with rapid drop in platelet . 2. Persistent vomiting (> 3 times over 24hrs) 3. Fluid accumulation (ascites, pleural effusion) 4. Lethargy / restlessness / confusion 5. Tender liver 6. Any abdominal pain / tenderness 7. Mucosal bleed