Monitoring for nurses
alert in Dengue patients
Rasana Waleerattanapa RN.
Queen Sirikit National Institute of Child Health
Medical Service Department, Ministry of Public Health
Bangkok, Thailand
Leading factors of the
spreading of Dengue
Population explosion
Migration
Increasing urbanization
Early rainy season
Contents:
Transmission
Pathophysiology
History
Screening
Equipment
Laboratory alert
Health education
1.Transmission of Dengue Virus
Extrinsic incubation
8-10 days
Viremia
High fever
Intrinsic incubation
5-8 days
2. Pathophysiology
Plasma Water Removal: Components
of Whole Blood
Plasma
(55%)
•92% water
•8% solutes
•Albumin
•Fibrinogen
•immunoglobulin
Cellular
Components
(45 %)
•RBC
•WBC
•Platelets
Hallmark
Abnormal
hemostasis
• Increased capillary fragility
TT+ petechiae / Bursie
•Thrombocytopenia
- Platelet drop
• Hepatomegaly
• If server to be DIC
Hypovolemic
shock
Plasma leakage 24-48 hrs.
Into serous spaces
Viscosity
Hct. rising
Hemodynamic
change
Volume decreased
Decreased Cardiac output
Circulatory
change
Pleural
peritoneal
Principle of treatment for Dengue
Volume replacement therapy
 Effective circulatory
 Adjust rate IV Transfusion by

- Hct.
- Clinical
- Vital sings
- Urine output
If the patient had got bleeding should
be give blood component
How to use electrolyte solution
Crystalloid :- Isotonic solution
- Osmotic P.= Plasma
- 5%D/NSS,5%DLR,5%DAR
Colloidal solution:- Plasma expander :
- Osmotic Pressure > Plasma 2-3 times,
e.g. 10% Dextran-40
- Plasma substitute: Osmotic pressure = plasma,
- e.g. plasma,
3.History
• Had got high fever T> 39oc
• Come from epidemic area
• Taken antipyretic –Paradol Temp not decease
• No URI symptoms just only new born
• Around house – Had people got Dengue
• Shopping to see the doctors at clinic,private
hospital
Who’s screening cases for DHF?
Health
personnel
Screening
OPD
Ward
• Epidemic area
• High fever
• History Day of
Fever
• Lab CBC- Hct
wbc,Plt.
• No fever reduce
• Lab CBC
Pre
sent
Tourniquet test
.Fragility
After take cuff off
Don’t count immediately
Wait for skin color
appear normal
Tourniquet Positive test
When there is > 10petechii per square inches
False negative tourniquet test
Obesity
 Very thin
Not good technique
During Shock
petechiae
no appear
Good technique – Pressure drop
4.Equipment:
Micro- centrifuge
Microscope
Sphygmomanometer
Supplies for using
Oral rehydration solution and
IV Fluid solution
ORS : Na 90 mEq
Na 75 mEq
Na 45 mEq
Kind of solution
5. Laboratory
Complete blood count
o Hematocrit > base line
o White blood cell < 5,000
o Platelet < 100,000
o Lymphocyte
+
Day of Fever ( D3,D4,D5)
CBC เปรียบเทียบผล
18
6.Health Education
Explained nature disease
 Home care: Bed rest, Soft diet, tepid sponging
Follow up everyday with CBC
Warning signs shock
 Prevention control -Get rid mosquito
Observation another person may be
Infected Dengue virus if high fever
Screening case by
take “ Tourniquet test”
Roles of Nurses
for caring
DF/DHF Patients
Natural course of Dengue
1. Febrile Phase
- high fever 2- 7 day
2. Critical/ Leakage Phase/
- Plasma leakage
- In 24-48 hrs. - Shock
3. Convalescence Phase –
- Recovery 2 – 7 days
1. Febrile Phase
Problem
o High fever/ headache/
retro – orbitalpain
o Dry lip, sore throat
o arthralgia
o Anoxia, nausea, vomiting
o Abdominal pain
Nursing Care:
 Vital signs q 4 hrs. – observe signs no fever
 Force ORS
 Monitoring rate IV & Care
 Follow result laboratory and notify
 Observe signs abnormal and notify
 Record Intake/Output
 Education to parent about course of Dengue
role of caring and prevention control
2.Leakage phase
Major complaints:
- Plasma leakage – Hct rising
- Plt. drop
- Circulatory disturbance
CR delay, bleeding
- Hepatomagary – Liver enlarge
 During time leakage
24 – 48 hrs.
Principle for nurses monitoring
Record Time Start Shock and Temp.
Count time after Temp. ( 24- 48 hrs.)
- During time leakage 24 -48 hrs.
- After Shock then 6 hrs,12 hrs,24 hrs.
Record IV Infusion, Type IV
Record urine /Shift
Notify Dr. Abnormal Signs &symptoms
1.Vital signs alert?
Rasana 06/12
Temperature every 4 hrs.
Temp.= 37.6 -38.4⁰ C
Temp.= 38.5 -39.0⁰ C
Temp.= 39.1 – 40.0⁰C
Temp.= > 40.1⁰ C
Low Fever
Middle Fever
High Fever
Very Fever
Pulse Rate = Peripheral pulse.
Effective= Heart Pumping and Circulatory
Assessment - pulse rate - อัตราการเต้น
- rhythm- จังหวะการเต้น
-amplitude - คลื่นกระทบ
- contour- ลักษณะ
Volume: - Full (F)
ความแรง
- Moderate (MF)
- Weak pulse ( W)
- Palpable
Blood Pressure
Blood pressure
(Manual/ digital)
– circulatory status
- Bleeding
Assessment – PP < 20 mmHg
- Narrow pulse pressure
100/80,90/70, 100/100
- Hypotension – 70/60
- Wide pulse pressure – Recovery
- Hypertension – Volume load
Respiratory rate
Assessment
 Rate 1 /min
 Rhythm -regularity, Dyspnea
 Depth
Abnormal RR:
> 60/ min Age 0-2 month
> 30/min Age 2 month – 1 years
> 40/min Age 1 – 5 years
> 28/min Age > 5 years
Vital Signs Alert
• BP PR q 2 hrs.
-if no fever or platelet <100,000
• - q 30 – 1 hr. in Shock gr III, IV
o Severity 4 grade - Non Shock gr I.II
- Shock gr III, IV
o Shock gr II- PP narrow Pulse rapid
o Shock gr IV – BP , Pulse palpable
Early signs and symptoms
When there is no fever ( or the peak of fever is lower
Not good symptoms

Restless, Irritable

Drowsy, very weak

Refuse to eat and drink

Very thirsty

Have cool extremities

Severe Abdominal pain

Persistent vomiting

Behavioral change

Cold clammy, Mottling skin

No urine for 4-6 hrs
BP Narrow < 20 mmHg
Rapid Pulse increase rate
Capillary Refill time > 2 sec.
Sings bleeding
 Bleeding per gum
 Epitaxis
 Coffee ground
 Melena
 Menstruation
Shock
2.Symptoms alert?
Problem in Dengue Shock case
o Plasma leakage – Hct. rising
Hemodynamic change
- Narrow Pulse pressure BP 100/80
- Rapid pulse
- Delay capillary refill
- Cold clammy skin
Nursing Diagnosis:
o Shock / Impending shock
o Abdominal pain - Liver enlarges
o Bleeding - Low platelet
o Electrolyte imbalance – Ica. Na
o Decease urine out - not effective
volume
Nurses activities:
IV
•Gr III
•rate 10
cc/kg/hr
•Gr IV rate Free
flow 10 -15
min.
•Hct, BS, CBC,
LFT,Coag, BG
Lab
•Group match bleeding
O2
Notify
Doctor
Monitor
V/S
IV Access
Hct. & DTX stat
•Via Oxygen
•Monitor O2 Sat
•Symptoms
•Signs
•CP >?
•Abnormal signs
• BP ,PR,RR every 10 15 min .until stable
• Control IV
•Follow Hct
•Record Urine output
•Correct complication
Oxygen sat
Via Oxygen
If can’t open IV Transfusion
 Force ORS immediately but patients
good conscious, can talk. ( with syringe)
 Prepare cut down set during wait the
physician
 Prepare cut down set
 Prepare set for insert Double
Lumen
Care IV Transfusion & Record intake
Type of IV – 5%D/NSS,5%DAR
Control flow rate follow order Dr.
Care Position
Record total infusion and ORS/shift
Care every 2-4 hrs.
Management procedure care IV rate
Urine output & Content from vomiting, bloody show
Record urine output every 8 hrs.
( Febrile phase)
Urine 0.5 ml/kg/hr (BW)
(Critical phase/Shock)
Record urine color
To known amount show blood renal
effective circulatory
Record amount content
Calculate of urine output:
 Volume may be effective circulatory
 Urine sp.gr < 1.015 mean effective volume.
fluid overload
> 1.015 mean dehydration/ disturbance

volume
 Volume/shift in 8 hours
Step calculation:
1 IBW
2. How many amount urine pass
3. Divide by 8 hours
4. Divide by IBW
Hematocrit (Hct.)
Febrile -Plt >100,000
- Dehydration Hct. 1-2% Per shift
Leakage Plt<100,000
Hct. 4-6 hr Adjust Rate IV
- Hct. Rising - leakage
- Hct. Drop – bleeding
Before & After blood transfusion
- Hct. may be 5% compare
after Load Dextran-40 complete 1 hr.
for Management IV
Important Nurse must to
know Base line patient Hct.
After 24-48 hrs. after plasma leakage
Indications in the convalescence phase
-Vital signs stable
- Wide pulse pressure
- Strong and slow pulse
- Hct. decrease
- Increase urine output
- Confluent petechial rash
3.Signs to convalescent phase:
A: Appetite
B : Base line Pulse rate BP normal ปกติ
C: Convalescent Rash-iching
D: Diuresis – more frequency
Hyper-volemia/
Hypertension/Dyspnea/Tachypnea
Nursing care
- V/S if High BP notify doctor
- Observe signs of fluid overload
- Fowler’s position
- Oxygen
- Discontinue IV fluid
- Give medication as in Dr.’s order
Convalescence Phase
Itching with or without Convalescence rash
Nursing care
-Explain
-Advice not to scratch
-Keep clean and dry skin
-Use talc powder/ calamine lotion
-Antihistamine if indicated
List monitoring of DHF patient
1. Vital Signs
2. Signs & Symptoms Notify doctors
3. Care IV Transfusion
4. Hematocrit (Hct.& Lab Test)
5. Urine output
6. Observer signs shock
7. Observe signs bleeding
8. Observe signs fluid overload
9. Observe signs liver failure, Renal failure
10. Notification
Cause of death in Dengue:
Prolong
Shock
Fluid
overload
Massive
Bleeding
Dead
Rasana 06/12
Leakag
e
Hematolog
ic changes
Circulatory
changes
- Platelet
drop
-BP,Pulse
-Hct rising
- Bleeding
Abnormal
symptoms
Fluid overload
Before
Shock
• IV before
Leakage
• Miss diagnosis
• N/2,N/3 hypotonic
• Hypotonic solution
During• Do not calculate IV /
Type
Shock• Not adjust the Rate
Hct./Urine output
After
Shock
Rasana 06/12
• Do not Off IV
Convalescent
phase
• Got Sign Fluid
overload
Signs & Symptoms
 Respiratory distress,e.g dyspnea Tachypnea
 Mark distended abdomen with massive ascites
 Rapid pulse (usually strong pulse)
 Narrowing of pulse pressure
 Crepitation and/or rhonchi
 Poor tissue perfusion (delayed capillary refill)
Symptoms
• Puffy eyelid
• Ascites
• Edema
• Restless
• Distress
Rasana 06/12
Signs
1.Vital signs :
-Rapid pulse: Age ,Rhythm
-Narrowing of pulse pressure
2.Respiratory distress:
-Rapid HR,RR ,Dyspnea, Tachypnea
-Poor tissue perfusion CR> 2 S
-Oxygen Sat drop>95%
Rasana 06/12
Monitoring:
Vital signs /.Respiratory distress
 Measure BP Pulse q 30-1 hr, 1-2 hrs/record
 Notify Rate Increase - Respiratory
- Distress
- Restlessness
- Ascites
- CR delay > 3 sec.
- Cool clamp
- O2 sat drop< 95%
 Prepare CPR
Rasana 06/12
Treatment monitoring:
Furosimide :Lasix
-Check V/S every 15 min 4 time
-Record urine pass
-Observe symptoms
- Notify when no urine pass,BP drop,Pulse rapid
Colloidal: 10%Dextran-40
- Control rate 10 cc/kg/hr
- Ending time charge type IV transfusion
- Notify Dr.
-Repeat Hct./Notify
-Observer symptom, Check V/S
Treatment monitoring:
Tapping:
-
Preparing set tapping
- Helping doctor tapping
- Record amount plural fluid
- Observe respiratory rate keep O2
- Observe Bleeding
- Follow lab. Electrolyte imbalance
Rasana 06/12
Treatment monitoring:
Intervention On ET Tube:
- Preparing set CPR
- Medicine for resuscitation
- Equipment
- Coordination for move to ICU
- Explain family patients
Rasana 06/12
Fluid overload:
- Pulmonary edema
- Respiratory Failure
- Pulmonary
congestion
DEAD
shock
and Massive bleeding
Rasana Waleearattanapa RN. Head of Dengue Ward
Queen Sirikit Institute of Child Health Bangkok, Thailand
Prolong Shock/ Massive Bleeding
Cause of prolong
shock
- From home
- At ER/Ward
- Shock not to
be improved
-Don’t diagnosis
shock
• Cause of bleeding:
- Had got bleeding
- Showed external
- Internal bleeding
- Prolong shock
4 grade Severity in Dengue
Non shock - Grade I = TT+
- Grade II = Bleeding
Shock grade - Grade III = Narrow pulse pressure
- Grade IV= No pulse rate and not
measure BP
Management for Dengue Shock gr III
Signs: Cold clammy. Rapid Pulse ,PP narrow
BP 100/80 mmHg, 100/100 mmHg
Restless, Weakness, No fever
IV resuscitation –
Isotonic rate IV 10 cc/kg/hr.Then 7cc/kg/hr
Hct.stat,and repeat Hct. Other lab
Notify Dr.
Monitor BP, PR every 30 min then 1 hr.
Management for Dengue Shock gr. IV.
Signs: Cold clammy. Can not catch Pulse, BP
Restless, weakness. drop fever,
CR> 2 sec
IV resuscitation – Isotonic free flow 5-10 min
follow BP,P if can measure reduce rate IV 10 cc/kg/hr.
Hct. And Sugar stat. other lab
Notify Dr.
Monitor BP, PR every 30 min then 1 hr.
Hemorrhagic manifestation:
• Tourniquet test positive
• Petechiea/Purpura/Ecchymoses
• Epistaxis
• Gum bleeding
• Hematremesis/ Melena
• Hypermenorrhea
Laboratory :
 Thrombocytopenia
– Platelet decrease 100,000
 Prolong PT/APTT – INR Prolong
 Coagulopathy – Impaired LFT
- AST /ALT
increase
 Hematrocrit drop > baseline
Severe bleeding:
• Gastrointestinal bleeding
- Hematemesis
- Helena
• CNS bleeding
• Hypermenorrhea
Bleeding :Symptoms
History got bleeding from home
Epitaxis, Coffee ground, hypermenorrhea
Hct. Drop
Pulse rapid, Hypotension
Prolong shock: Hypoxia
 Consciousness change: Restless
 Cold Clammy peripheral CR > 2 sec.
O2 situation < 95%
Bleeding
Activities:
- Notify doctor amount of bleeding
- Stat Hct. And DTX BG
- Preparing blood component
- Monitor oxygen saturation
- V/S q 1-2 hrs
- Control rate blood transfusion
- Observe signs blood allergy
Rasana 06/12
Observe Bleed in Brain
Symptoms
- BP drop HR -Tachycadia
- Conscious change rapid
- Neuro-signs GCS decease
- O2 Sat drop < 95%
- Bleeding - Coffee ground, Melena
- CT Brain-Brain edema, bleed
Rasana 06/12
Complications:
Bleeding
Shock/
Electrolyte
imbalanc
e
Leakage
phase
Liver
failure
Renal
failure
Fluid
overloa
d
Circulator
y
Change
Complication in Dengue severity cases
Metabolic Acidosis
Electrolyte Imbalance
- Hypoglycemia
- Hypocalcemia
- Hyponatremia
- Hypokalemia
Hepatic Failure
 Acute Renal Injury
Rasana 06/12
Electrolyte imbalance
Hypoglycemia
- Follow BS/DTX
- Force oral fluid ors/juice
- Keep warm
- Check V/S q 2 hrs.
Electrolyte imbalance
Hypocalcemia
- Observe convulsion/record duration
- Take 10%Ca gluconate dilute 1:1 push slow
- Notify Dr, Lab Ca < 8.5 mg%
- Monitoring V/S .N/S
Electrolyte imbalance (conc.)
Hyponatremia & Hypokalemia
- Follow lab Na,K and Notify
- Change type IV
- Take % sodium chloride
- Force juice with high Na,K
- Monitoring V/S.N/S
Rasana Waleerattanapa RN
Queen Sirikit National Institute of Child Health
2.Liver loss ability to functions:
80 -90% of liver cell were damaged
Causes:
 Infected Dengue virus –Kuffer cell
 Impaired Protein Synthesis
• Serum Albumin decease
• Prothrombin time prolong
Coagulopathy: Lab:

PT,PTT,INR prolong
Coagulation Factor: Factor VII, X ,V
Prothrombin time
Finding Bleeding
Severity of hepatic injury
AST/ALT
Significant of Platelet dysfunction:
THROMBOCYTOPENIA
Platelet decrease
(loss larger and active)
Vitamine K
Disseminated Intravascular Coaglulation (DIC) If
prolong shock
Cause for liver failure in Dengue
 Prolong shock/ hemorrge
 Hemoconcentrate  plasma leakage
 Hct rising
 Blood flow decrease
 Liver dysfunction
Classification of ALF;
o Hyperacute -on set 7 days
o Acute - onset 8- 20 days
o Subacute - 4-12 weeks
*Most of DHF on Acute*
Laboratory finding:
 Platelet count- low < 20,000
 Prolong- PT,PTT,INR > 1.3
 Enzyme increase :
- AST/ALT >1,000
- Albumine< 3.5
Clinical features of encephalopathy by grade
Grade
Clinical Features
1
Confuse, Altered mood, mild or episode drowsiness,
impaired intellectual and concentration, decrease
psychomotor function, rousable
2
Increased drowsiness with confusion and disorientation,
inappropriate behavior, rousable
3
Very drowsy and disorientated, response to simple verbal
command, often agitated and aggressive, markedly
confused behaviour
Response to painful stimuli at best or coma unresponsive,
may be complicated by evidence of cerebral edema
4
Symptoms:
o High fever
o Pain in the upper right area of abdomen
o Ascites (build up of fluid in the abdomen)
o Nausea, Vomiting
o Loss of appetite and weakness
o A general sense of not feeling well
o Disorientation or confusion
o Sleepiness
Problem : Fever
Symptoms : High Fever > 38⁰ C - 40⁰ C
Cause : Liver infection - dysfunction
Aim: Prevent convulsion & heat stoke
Nursing: -Tepid sponge
-Lie on mattress bed
for decrease temperature
-Check temperature every 2-4 hrs.
Problem : Abdominal pain and Ascites
Symptoms : Tender and Not comfortable lie
Cause
: Liver enlarge and build up of
fluid in the abdomen
Aim: Release pain and support
Nursing:- Cold compress
- Comfortable position
- Observe pain score and notify
Problem : Nausea, Vomiting/
Loss of appetite and weakness
Symptoms : continue vomiting/ nausea / refuse to eat
Cause : liver loss function metabolic
Aim: Promotion to eat and drink
Nursing: - Special mouth wash
- Soft diet and low fat
- Follow laboratory electrolyte.
etc. Na, K
- Observe Neuro-signs
Problem : Disorientation or confusion
Symptoms : Behavior change, speak bowl
Cause : NH3 load in circulation to abrupt brain
Aim: Prevent to development hepatic encephalopathy
Nursing: - Observe N/S, V/S q 1-2 hrs.
- Observe consciousness GCS
- Follow laboratory
- Notify doctor if the patients
abnormal signs
Problem : Rick to bleeding
Symptoms : bruise or
Cause : low platelet
Aim: Prevent to bleeding
Nursing: - Stop bleed before taken blood test
- Observe bleeding
- Follow laboratory PT/PTT/INR
- Do not invasive procedure
- Follow Hct.
Management of liver failure in Dengue cases:
 Control hypoglycemia
 Given antibiotic - Cefotaxine, Lactulose
 Severe cases may be blood exchange or
hemodialysis
 Restrict food- low protein
 Control electrolyte – complication
 Control blood loss – If the Hct. Drop
o
o
o
o
o
o
o
o
How to detection entering to Liver failure:
Prolong Shock with Massive bleeding
Severity leakage (Gr III, Gr IV, DSS)
Fluid overload
Got high fever continuous
Lab: SGOT> SGPT = > 1000 Unit
Severity bleeding
Referral Cases
High risk cases
Nursing care for acute
Kidney injury
Dengue hemorrhagic
fever
Pediatric-modified RIFLE criteria
GFR
Criteria
Urine Output Criteria
Risk
Increase Cr x1.5 or
GFR decrease > 25%
UO < 0.5 ml/kg/hr x 8 hrs.
Injury
Increase Cr x2 or
GFR decrease > 50%
UO < 0.5 ml/kg/hr x 16hrs.
Failure
Increase Cr x3 or
GFR decrease > 75%
Or
C rx 4 mg/unit
UO < 0.3 ml/kg/hr x 24 hrs.
or
Anuria for 12 hrs.
Loss
Persistent acute kidney failure and
excretion loss of renal function> 4 weeks
End Stage Renal Disease Persistent failure > 3 months
ESRD
Causes of acute kidney failure
1.
Prerenal – Azotenia
- Low blood volume
- Low blood pressure
- Thrombosis
- Blood clot
- Renal is ischaemia
2. Intrinsic
- GFR decrease
- Acute interstitial nephritis
3. Postrenal
- Urinary tract loss
- No urine pass
2
1
3
Renal manifestations in DHF
 Mild urinary abnormalities include
- Proteinuria
- Hematuria
- Oliguria
- Rising of BUN/Cr.
Signs and Symptoms:
Fatigue
Loss Appetite
Headache
Nausea/Vomiting
Urine decease
Color of urine change
Monitoring :
Record urine output
Color of urine
 Volume of urine/shift
 Force ORS
 Follow lab: BUN/Cr
Natural course of Dengue
Febrile – Urine 1.0 cc/kg/hr.
Leakage – Urine 0.5 cc/kg/hr.
Recovery – Urine > 1.0 cc/kg/hr.
Treatment monitoring:
Furosimide :Lasix (1mg/kg/dose)
- Check V/S every 15 min 4 time
- Record urine pass
- Observe symptoms
- Notify when no urine pass
- BP drop,Pulse rapid
08/10/09
Treatment for AKI
Peritoneal dialysis
Hemo-dialysis
CRRT
Rasana 06/12
Continuous Renal Replacement Therapy
( CRRT)
o SCUF – Slow Continuous Ultrafitration
- Ultrafiltration - water
o CVVH – Continuous Veno-Venous Hemofiltration
- Convection
- Water & Solutes
o CVVHD -Continuous Veno-Venous
Hemodialysis - Diffusion
o CVVHDF -Continuous Veno-Venous
Hemodiafiltration
- Diffusion & Convection
( 3&4 water & Solutes small molecules
Control of Uremia)
4’ E Concern
for Dengue cases
1.E
2.E
3.E
Early Detection
Early Notification
Early Intervention & Treatment
4. E
Early Prevention control