Saint Gabriel College

COLLEGE OF NURSING
Old Buswang, Kalibo, Aklan

In partial fulfillment of the requirements in

Related Learning Experience
NCM-104 Community Health Nursing - Skills

Dengue

PRESENTED BY:

Clarence J. Cabaong
John Bern D. Valenzuela
Dan Andrei Billiones
 Mrs. Shiela S. Matorre, RN, MAN
NCM – 104 (Skills) Instructor

Dengue

Dengue is a public health problem in the Philippines. The disease once associated with
the rainy season and has begun to change its pattern in the country. Although the case fatality
rate decreased in 2005, recent statistics shows that dengue cases in the Philippines increased
in 2009 to its peak with 57,819 cases (WHO, 2010). The sudden change of pattern may be
attributed to climate change and urbanization since the vector of the disease proliferates in
congested urban areas. Further, the DOH declared a national dengue outbreak in 2019 due to
the alarming increase in the number of cases admitted in various health facilities.
Causative agents:
 Dengue virus (DEN), a single stranded RNA virus of four types genus
Flavivirus, family Flaviviridae. All of the four types have been isolated in the
country. Therefore, a person can get the infection four times since there is no
cross-immunity between types. However, lifetime immunity is possible for a
specific type of virus.
 Vectors:

1. Aedes Aegypti - also known as yellow fever mosquito or tiger mosquito

is the principal vector predominant in urban areas seen in tropical and
subtropical countries. It proliferates in clean, clear and unpolluted
stagnant bodies of water used for domestic water storage or rain filed
habitats like flower vases, concrete water tanks, discarded vehicle tires,
and any other containers which can accumulate water up to 7 days.
Typically, these mosquitoes fly within 100 meters radius from the
breeding place with a flight range of 50 meters. It feeds almost entirely on
humans at dusk, just before sunset, and at dawn, just after sunrise indoors.
As a domestic mosquito, Aedes aegypti prefers to rest in cool, dark
corners of the house. Commonly, they are found in closets, under beds,
tables and chairs.

2. Aedes Albopictus – also known as Asian tiger mosquito is the secondary

vector predominant in rural areas that proliferates in leaf axils, tree holes,
bamboo stumps, coconut shells or husks, ground or deep holes. It feeds
on other mammals aside from humans during daylight outdoors (Estrada-
Franco & Craig, 1995). Unlike an aegypti, it usually rest in clearings and
vegetations, and can survive even in cold temperatures (Romi, 2006). It
can fly within 200 meters radius from the point of origin with a flight
 range of 180 meters. Moreover, It is the only mosquito that can transmit
chikungunya virus (Hoschedez,2006).
3. Aedes Polynesiensis – This mosquito is found primarily in the Pacific
Islands. It is known to be a vector for diseases like dengue and Zika,
although it’s less widespread compared to Aedes aegypti and Aedes
albopictus.

4. Aedes Scutellaris – This species is found in Southeast Asia and is known

to transmit lymphatic filariasis. While it is not a significant vector for
dengue or Zika, it can still be a concern in endemic regions.

“It’s important to note their characteristics to control these vectors in transmitting

dengue. However, common to these mosquitoes is their eggs are found in water-filled
habitats closely associated with human dwellings” (Hill et al., 2008).

Mode of Transmission:
 Bite of mosquitoes
Incubation Period:
 3 To 14 days, commonly 5 to 7 days
Susceptible:
 All individuals regardless of age, gender, or geographic location are at risk.
However, children between 0-9 years are commonly affected based on age
distribution. Moreover, the epidemics frequent in populated areas with poor
environmental conditions conducive for vector breeding.

Laboratory/Diagnostic Examination:
1. Tourniquet test or Rumpel-Leads test - It measures the coagulability of the blood
by applying a tourniquet on a client’s extremity and observing the amount of petechiae
produced. It is the presumptive test for dengue that is used to assess bleeding
tendencies of a patient suspected to have the disease (Halstead, 2008). Before doing
the test, the public health nurse must explain the procedure and purpose, and assess s
the individual’s arm for any petechiae,ecchymoses, or infections that may affect the
result. It is also contraindicated for individuals with fistula, arteriovenous shunt, or has
undergone mastectomy(Daniels, 2009). The public health nurse must inform the
individual that it may be uncomfortable for a while but not painful. In performing this
test, the nurse will place the sphygmomanometer on the upper arm of the individual
and inflate the blood pressure cuff to a point midway between the systolic and
 diastolic pressure for 5 minutes. Then, release the cuff and make an imaginary 1-inch
(2.5 cm) square just below the cuff, at the antecubital fossa. Finally, inspect and count
the number of petechiae in a 1-inch(2.5cm) square. A positive result would mean the
presence of more than 20 petechiae per 1-inch (2.5cm) square.

2. Capillary Refill Test or Nail Blanch Test – Capillary refill is the rate at which blood
refills empty capillaries. It measures dehydration and decreased peripheral perfusion
for patients with dengue. It can be measured by holding a hand higher than heart-level,
then press the soft pad of the thumb nail or toe nail until it turns white or blanching
occurs. Release the pressure and measure the time needed for the color to return or
once pressure is released. Normal refill time is less than 3 seconds. Hence, more than
3 seconds is a warning sign.

3. Platelet Count and Hematocrit Count – To confirm the diagnosis of dengue,

laboratory test such as platelet and hematocrit count should be performed. A rapid
decrease in platelet count (150,000 to 400,000 cu.mm) in parallel with a rising
hematocrit(F = 36-46%, M = 41-53%) is suggestive of progress to the critical phase of
dengue. If no proper laboratory services are available, the minimum standard is the
point-of-care testing of hematocrit by capillary (finger prick) blood sample with the
use of a micro centrifuge (WHO, 2009).

4. Hemagglutination-inhibition (HI) test – This test is frequently used for patients

admitted in the hospital since this test would require paired sera. The HI test is based
on the ability of dengue virus antibodies to inhibit agglutination (WHO, 2009).

5. Dengue NS1 Kit – This test is available in all RHU’s in the country for rapid
detection of Dengue antigen by dropping blood samples on a cartridge similar to a
pregnancy test kit It is requested in 1 to 5 days of illness.

Dengue Case Classification:

Due to the wide different clinical presentations and unpredictable clinical evolution
and outcome, a new model for classifying dengue has been developed by WHO expert
consensus group. It is practical to use and aids the clinician in deciding as to where and
 how intensively the patient should be observed and treated. Table 15.7 shows dengue
Case classification and levels of severity.
Phases of Illness:
1. Febrile Phase lasts 2 to 7 days-high-grade fever, facial flushing, skin erythema,
generalized body ache, myalgia, arthralgia and headache. Some may have
sorethroat,infected pharynx and conjunctival infection,Anorexia, nausea and
vomiting are common. A (+) tourniquet test result increases the probability of
dengue. Therefore, monitoring for warning signs and other parameters is needed to
recognize progress to critical phase. Mild hemorrhagic manifestations like
petechiae and redness on mucosal membrane(nose and gums) may be seen. A
progressive decrease in total white cell count in the blood would alert the nurse to a
high probability of dengue.

2. Critical Phase lasts 24 to 48 hours-when the temperature drops and remains below
37.5-38’C or less usually on day 3-7 of illness, an increase in capillary
permeability with increasing hematocrit levels may occur. Rapid decrease in
platelet count usually precedes plasma leakage. Pleural effusion and ascites may be
detectable. Shock may occur when a large amount of plasma is lost through
leakage that is preceded by warning signs. Prolonged shock results to organ
impairment(severe hepatitis, encephalitis, myocarditis).metabolic acidosis, and
disseminated intravascular coagulation .

3. Recovery Phase usually takes place in the following 48-72 hours. The general
well-being improves, appetite returns, gastrointestinal symptoms subsides,
hemodynamic status become stable.
Treatments:
Management for: Dengue is symptomatic and supportive. Follow-up is also important
for proper observation and monitoring of patients. All suspected cases of Dengue
should be referred to a health facility immediately for proper management and to
prevent complications.

1. Give Paracetamol every 4-6 hours. If the patient still has high fever, do tepid
sponge bath. Do not give acetylsalicylic acid(aspirin), ibuprofen or other
non-steroidal anti-inflammatory agents (NSAIDs) as these drugs may
aggravate bleeding. Acetylsalicylic acid (aspirin) may be associated with
Reye’s syndrome among children.

2. Encourage oral intake of oral rehydration solution (ORS), fruit juice and
other fluids containing electrolytes and sugar to replace losses from fever
and vomiting. ORS like ORESOL can be given at 75 ml/KBW in 4 hours to
 children or 2-3 liters in adults. If not tolerated, start intravenous fluid therapy
of 0.9% saline or Ringer’s lactate with or without dextrose at maintenance
rate.
3. Advise the patient to avoid dark colored foods that can mask bleeding. Diet
should be low fat, low fiber, non-irritating, non-carbonated.

4. Ensure strict bed rest and protect patient from trauma to reduce the risk of
bleeding.

5. Do not give intramuscular injections to avoid hematoma.

6. Instruct the care-givers that the patient should be brought to hospital

immediately if any of the following occur: no clinical improvement,
deterioration around the time of defervescence, severe abdominal pain,
persistent vomiting, cold and clammy extremities, lethargy or
irritability/restlessness, bleeding (e.g. black stools or coffee-ground
vomiting), not passing urine for more than 4-6 hours.

7. For nose bleeding (epistaxis), maintain an elevated position and apply ice
compress to promote vasoconstriction. If there is bleeding of gums, give ice
chips and advise the patient to use soft-bristled toothbrush. For
gastrointestinal bleeding, place the patient on NPO.

8. Blood transfusion should be given as soon as severe bleeding is suspected or

recognized. However, blood transfusion must be given with care because of
the risk of fluid overload.

9. In cases of shock, place client in dorsal recumbent position to promote

circulation.

10.Monitor laboratory results such as platelet and hematocrit count accordingly.

Those with stable laboratory results, without fever or there is no danger signs
for 72 hours can be sent home after being advised to return to the hospital
immediately if they develop any of the warning signs such as abdominal pain
or tenderness, persistent vomiting, clinical fluid accumulation, mucosal
bleeding, lethargy, and restlessness.

Enhanced Four “S” Strategy for Dengue Prevention (DOH, 2018)

1. Search and destroy breeding places of mosquito.
2. Seek early consultation and immediate Treatment
 3. Self protection measures.
4. Say yes to fogging only during outbreaks.

Reference:
 Centers for Disease Control and Prevention. (n.d.). Aedes mosquitoes.
Retrieved from https://www.cdc.gov

 Halstead, S. B. (2008). Dengue. Springer.

 Nies, M. A., McEwen, M., & Sumile, E. F. R. (Eds.). (n.d.). Community and
public health nursing (2nd Philippine ed.). Elsevier.

 World Health Organization. (n.d.). Aedes mosquitoes and their role in

transmitting diseases. Retrieved from https://www.who.int