Microbiology and Parasitology - Lab

Module #10 Student Activity Sheet

Name: _________________________________________________________________ Class number: _______

Section: ____________ Schedule: ________________________________________ Date: ________________

LESSON TITLE: DENGUE FEVER AND DIPHTHERIA Materials:

Pen, paper, index card, book, and class List
LEARNING OUTCOMES:
At the end of the lesson, the nursing student can:
1. Describe what is dengue fever and diphtheria; Reference:
2. Explain the mode of transmission of dengue fever and
diphtheria; Navales D., (2010). Handbook of Common
rd
3. Identify the etiologic agent dengue fever and diphtheria; Communicable and Infectious Diseases 3
4. Restate the pathophysiology of dengue fever and diphtheria; Edition, Philippines: C&E Publishing Inc.
5. Enumerate the signs and symptoms of dengue fever and
diphtheria; and, https://nurseslabs.com/dengue-hemorrhagic-
6. Outline the different nursing management of dengue fever fever/
and diphtheria.

A. LESSON PREVIEW/REVIEW (5 minutes)

Instruction: What is the best way to prevent the spread of COVID-19. Explain your answer.
_________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________.

B.MAIN LESSON (50 minutes)

Content and Skill-Building

Dengue Fever
⎯ Dengue fever is an acute febrile disease caused by infection with one of the serotypes of dengue virus. It is a
mosquito-borne disease caused by genus Aedes.
⎯ Dengue is also known as Break-bone Fever, Hemorrhagic Fever, Dandy Fever, Infectious Thrombocytopenic Purpura.
⎯ Dengue hemorrhagic fever is a fatal manifestation of dengue virus that manifest with bleeding diathesis and
hypovolemic shock.
⎯ These viruses are related to the viruses that cause the West Nile infection and yellow fever.

Causative Agent:
⎯ Flavivirus, a family Togaviridae a small, single strand RNA
⎯ Arboviruses (transmitted by mosquitoes or ticks) Group B

Four Serotypes of Dengue Virus: DEN-1, DEN-2, DEN-3, DEN-4

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 Microbiology and Parasitology - Lab
Module #10 Student Activity Sheet

Name: _________________________________________________________________ Class number: _______

Section: ____________ Schedule: ________________________________________ Date: ________________

Mode of transmission:
⎯ By bite of mosquito, Aedes Egypti
✔ A day-biting mosquito (they appear two hours after sunrise and two hours before sunset)
✔ It breeds on stagnant water.
✔ It has a limited and low-flying movement.
✔ It has fine white dots at the base of the wings; with white bands on the legs.
⎯ Aedes albopictus may contribute to transmission of dengue virus in rural areas.
⎯ Aedes polynensis
⎯ Aedes scutellaris simplex

Incubation period:
⎯ 3 to 14 days; 7 to 10 days

Period of communicability:
⎯ Patients are infective to mosquito from a day before the febrile period to the end of it.
⎯ The mosquito becomes infective from day 8 to 12 after the blood meal and remains infective all throughout its life

Sources of infection:
⎯ Infected persons, the virus is present in the blood of patients during the acute phase of the disease and will become
a reservoir of virus, sucked by mosquito which may then transmit the disease.
⎯ Stagnant or standing water, water along the household and premises are usual breeding places of these
mosquitoes.

Pathophysiology
The pathophysiology of dengue hemorrhagic fever includes:
⎯ Initial phase. The initial phase of DHF is similar to that of dengue fever and other febrile viral illnesses. The virus is
deposited in the skin by the vector, within few days viremia occurs, lasting until the 5th day for the symptoms to show.
⎯ Hemorrhagic symptoms. Shortly after the fever breaks or sometimes within 24 hours before, signs of plasma
leakage appear along with the development of hemorrhagic symptoms.
⎯ Vascular leakage. Vascular leakage in these patients results in hemoconcentration and serous effusions and can
lead to circulatory collapse.
⎯ Progression. If left untreated, DHF most likely progresses to dengue shock syndrome.

Statistics and Incidences

⎯ Globally, 2.5 to 3 billion individuals live in approximately 112 countries that experience dengue transmission.
⎯ Annually, approximately 50-100 million individuals are infected.
⎯ Dengue fever has a mortality rate of less than 1%.
⎯ When treated, DHF has a mortality rate of 2-5%, but when left untreated, the mortality rate is as high as 50%.
⎯ Dengue fever may occur at any age but is more common among children.
⎯ More frequent during the rainy season.

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 Microbiology and Parasitology - Lab
Module #10 Student Activity Sheet

Name: _________________________________________________________________ Class number: _______

Section: ____________ Schedule: ________________________________________ Date: ________________

Clinical Manifestations
⎯ Symptoms, which usually begin 4 to 6 days after infection and may last to up to 10 days, include:

⎯ High fever. Sudden high fever (39 to 40) occurs as a result of the infection.
⎯ Severe headaches. Severe headaches also torment the patient.
⎯ Herman’s sign. Maculopapular or petechial rash maybe present that starts at the distal portion of the extremities
(sparing the axilla and chest), the skin appears purple with blanched areas with varied sizes.
⎯ Damage to lymph and blood vessels. As the virus slowly spreads, even the lymph and blood vessels are affected.
⎯ Bleeding. Bleeding from the nose and gums is a characteristic of DHF.
⎯ Enlargement of the liver. The dengue virus could also penetrate the liver, causing fatal damage.
⎯ Circulatory system failure. The circulatory system ultimately fails eventually if the disease is not treated promptly.
⎯ Hemorrhagic manifestations
✔ (+) tourniquet test
✔ Purpura
✔ Epistaxis
✔ Gum bleeding

Classification According to Severity:

1. Grade 1 - there is fever, w/ positive tourniquet test
2. Grade II - all signs in grade 1 plus spontaneous bleeding from the nose, gums, GIT
3. Grade III - presence of circulatory failure weak pulse, narrow pulse pressure, hypotension, cold clammy skin, and
restlessness.
4. Grade IV - profound shock, undetectable BP, and pulse

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 Microbiology and Parasitology - Lab
Module #10 Student Activity Sheet

Name: _________________________________________________________________ Class number: _______

Section: ____________ Schedule: ________________________________________ Date: ________________

Complications
Some complications are:
1. Dengue fever:
⎯ Epistaxis, menorrhagia
⎯ GI bleeding
⎯ Peptic ulcer
2. Dengue Hemorrhagic Fever
⎯ Metabolic acidosis
⎯ Myocarditis
⎯ Hyperkalemia
⎯ Tissue anoxia
⎯ CNS hemorrhage or adrenal glands
⎯ Uterine bleeding
3. Severe Manifestations
⎯ Dengue encephalopathy: Restlessness, apprehension or anxiety, disturbed sensorium, convulsions, spasticity, and
hyporeflexia

Diagnostic tests:
⎯ Tourniquet test is done by occluding the arm veins for about 5 min, to detect capillary fragility
⎯ Platelet count (decreased). This test confirms dengue
⎯ Hemoconcentration (20% increase in the hematocrit) secondary to plasma extravasation and/or third-space fluid loss.
⎯ Occult blood test
⎯ Hemoglobin determination

Treatment modalities
⎯ No effective antiviral therapy for dengue fever
⎯ Treatment is entirely symptomatic
✔ Oral rehydration therapy. Oral rehydration therapy is recommended for patients with moderate dehydration
caused by high fever and vomiting.
✔ IV fluids. IVF administration is indicated for patients with dehydration.
✔ Blood transfusion and blood products. Patients with internal or gastrointestinal bleeding may require
transfusion, and patients with coagulopathy may require fresh frozen plasma.
✔ Oral fluids. Increase in oral fluids is also helpful.
✔ Avoid aspirins. Aspirin can thin the blood. Warn patients to avoid aspirins and other NSAIDs as they increase the
risk for hemorrhage.
✔ Antipyretics. Intended for fever
✔ Analgesics. Intended headache, ocular pain, and myalgia

Prevention
There are many ways to prevent dengue fever but there are no vaccines available yet.
⎯ Avoid crowded places. Stay away from heavily populated residential areas.
⎯ Mosquito repellents. Use mosquito repellents that are mild for the skin, even indoors.
⎯ Proper clothing. When outdoors, wear long-sleeved shirts and long pants tucked into socks.
⎯ Mosquito-free environment. Make sure window and door screens are secure and free of holes or use mosquito
nets.
⎯ Stagnant water. Empty or cover bottles, cans, and any containers with stagnant water as these can become breeding
places of mosquitoes.

Nursing Management
Nursing management of patients with DHF is essential in achieving complete recovery.

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 Microbiology and Parasitology - Lab
Module #10 Student Activity Sheet

Name: _________________________________________________________________ Class number: _______

Section: ____________ Schedule: ________________________________________ Date: ________________

Nursing Assessment
Assessment of a patient with DHF should include:
⎯ Evaluation of the patient’s heart rate, temperature, and blood pressure.
⎯ Evaluation of capillary refill, skin color and pulse pressure.
⎯ Assessment of evidence of bleeding in the skin and other sites.
⎯ Assessment of increased capillary permeability.
⎯ Measurement and assessment of the urine output.

Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses for a patient with DHF are:
⎯ Risk for bleeding related to possible impaired liver function.
⎯ Deficient fluid volume related to vascular leakage.
⎯ Pain related to abdominal pain and severe headaches.
⎯ Risk for ineffective tissue perfusion related to failure of the circulatory system.
⎯ Risk for shock related to dysfunction in the circulatory system.

Nursing Care Planning and Goals

The goals in a patient with DHF are:
⎯ Be free of signs of bleeding.
⎯ Display laboratory results within normal range for individuals.
⎯ Maintain fluid volume at a functional level.
⎯ Report pain is relieved or controlled.
⎯ Follow prescribed pharmacologic regimen.
⎯ Demonstrate adequate tissue perfusion.
⎯ Display hemodynamic stability.
⎯ Be afebrile and free from other signs of infection.

Nursing Interventions
Nursing interventions appropriate for a patient with DHF include:
⎯ Blood pressure monitoring. Measure blood pressure as indicated.
⎯ Monitoring pain. Note client report of pain in specific areas, whether pain is increasing, diffused, or localized.
⎯ Vascular access. Maintain patency of vascular access for fluid administration or blood replacement as indicated.
⎯ Medication regimen. There must be a periodic review of the medication regimen of the client to identify medications
that might exacerbate bleeding problems.
⎯ Fluid replacement. Establish 24-hour fluid replacement needs.
⎯ Managing nose bleeds. Elevate position of the patient and apply ice bag to the bridge of the nose and to the
forehead.
⎯ Trendelenburg position. Place the patient in Trendelenburg position to restore blood volume to the head.

Evaluation
A successful nursing care plan has achieved the following:
⎯ Absence of signs of bleeding.
⎯ Displayed laboratory results within normal range for individuals.
⎯ Maintained fluid volume at a functional level.
⎯ Reported pain is relieved or controlled.
⎯ Followed prescribed pharmacologic regimen.
⎯ Demonstrated adequate tissue perfusion.
⎯ Displayed hemodynamic stability.
⎯ Afebrile and free from other signs of infection.

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 Microbiology and Parasitology - Lab
Module #10 Student Activity Sheet

Name: _________________________________________________________________ Class number: _______

Section: ____________ Schedule: ________________________________________ Date: ________________

Diphtheria

Diphtheria is an acute bacterial disease that can infect the body in two areas:
⎯ Throat (respiratory diphtheria)
⎯ Skin (skin or cutaneous diphtheria)

Causative Agent: Corynebacterium Diphtheriae (Klebs-Loeffler bacillus)

⎯ A toxin-producing bacterium
⎯ Manufactures exotoxin (poisonous substance produced during the growth of a microorganism) which is responsible
for major pathologic changes
⎯ A gram (+), non-sporulating, and generally aerobic.
⎯ Unstable and easily destroyed by light, heat and aging.
⎯ It is capable of damaging muscles, especially the kidneys, liver, cardiac nerves and other tissues.

3 strains:
a. Gravis (severe) strain that produces fatal cases.
b. Mitis (mild) strain that produces lesions extending to the larynx and the lungs.
c. Intermedius (intermediate) results to tendency to bleed.

Incubation period:
⎯ Symptoms develop in 2 to 5 days

Period of communicability:
⎯ 2 to 4 weeks for untreated patients
⎯ 1 to 2 days for treated patients

Source of infection:
⎯ Discharges of the nose, pharynx, and eyes, or lesions on other parts of the body of an infected person.

Mode of transmission:
⎯ Direct contact
⎯ Indirect contact through articles soiled w/ discharges of an infected person.

Predisposing Factors:
⎯ Operation in an area of the nose and throat
⎯ Economic status
⎯ Lack of proper nutrition
⎯ Overcrowding

Pathognomonic sign:
⎯ Grayish pseudo-membrane found over the tonsils, pharynx or larynx.
⎯ The toxin produces nerve damage, resulting in paralysis of the soft palate, eye muscles, or extremities
⎯ The size of the pseudo-membrane reflects the amount of toxin produced. The larger the size of the pseudomembrane,
the more toxins are present in the bloodstream and in the tissues.
⎯ Any attempt to remove the pseudo-membrane, exposes and tears the capillaries, resulting in severe bleeding.

Types:
a. Nasal with foul-smelling serosanguinous secretions from the nose.
b. Tonsillar with low fatality rate. Lesions are confined to the tonsils, but may extend over the soft palate and uvula.

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 Microbiology and Parasitology - Lab
Module #10 Student Activity Sheet

Name: _________________________________________________________________ Class number: _______

Section: ____________ Schedule: ________________________________________ Date: ________________

c. Facial nasopharyngeal
⎯ Cervical lymph nodes are swollen
⎯ Edematous neck, “bull’s neck”.
⎯ Marked degree of toxemia
⎯ Breath is fetid (malodorous)
d. Laryngeal
⎯ Most commonly found in children (2 to 5-year-old)
⎯ Most severe and fatal due to possibility of obstructing the airway from severe inflammation.
⎯ Increased RR because less air is brought to the lungs, air passages are narrowed.
⎯ Moderate hoarseness of voice, or absent voice.
e. Wound or cutaneous
⎯ Affects the break in the skin
⎯ Symptoms are milder, may include yellow spots or sores

Clinical manifestations:
⎯ Fatigue, malaise, sore throat and fever,
⎯ Exudates in the throat
⎯ Exudates are formed into gray membrane, and as they thicken, they become dull white.
⎯ Cervical adenitis or the infection of the lymph node in the neck
⎯ swollen neck (bull’s neck), and edema may extend to the chest.
⎯ Laryngeal membrane may extend to the trachea, resulting in respiratory problem

Complications:
⎯ Myocarditis which is the inflammation of the heart muscle. Myocarditis is caused by the action of diphtheria toxin on
the heart muscles.
⎯ Polyneuritis, paralysis of the soft palate, pharynx, larynx, or extremities
⎯ Airway obstruction w/c may lead to asphyxiation
⎯ Cervical adenitis
⎯ Otitis media
⎯ Bronchopneumonia

Diagnostic test:
⎯ Swab from nose and throat
⎯ Virulence test is used to test for the toxigenic effect of C. Bacteria.
⎯ Schick test is used to determine susceptibility to bacteria
⎯ Molony test is a test for hypersensitivity to diphtheria toxin
⎯ Loefler medium slant is used in culture of C. bacteria.

Treatment:
⎯ Penicillin is effective in treating respiratory diphtheria before it releases toxins in the blood
⎯ Skin testing of anti-diphtheria toxin
⎯ Erythromycin

Supportive Therapy:
⎯ Adequate nutrition
⎯ Adequate F&E balance
⎯ Bed rest
⎯ Oxygen inhalation
⎯ Care of the tracheostomy

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 Microbiology and Parasitology - Lab
Module #10 Student Activity Sheet

Name: _________________________________________________________________ Class number: _______

Section: ____________ Schedule: ________________________________________ Date: ________________

Nursing management:
⎯ Bedrest for at least 2 weeks
⎯ Soft diet is recommended. Small frequent feeding
⎯ Vitamin C to increase resistance; fruit juice
⎯ Ice collar to the neck
⎯ Proper disposal of nasal and throat discharges

Prevention:
⎯ Isolation for a minimum of 14 days
⎯ Avoid contact with children and avoid handling food
⎯ Children under 5-year-old should be given booster dose
⎯ Mandatory DPT immunization for babies.

Vaccine Dosage Route Interval Site Timeframe

DPT 1 0.5 mL IM 4 weeks Vastus lateralis 6 weeks

DPT 2 0.5 mL IM 4 weeks Vastus lateralis 10 weeks

DPT 3 0.5 mL IM 4 weeks Vastus lateralis 14 weeks

Who could receive vaccine:

⎯ Children with moderate or severe fever, as soon as they recover.
⎯ Children with minor illness like URTI, with or without fever.
⎯ HIV infected person.

Contraindication for DPT Vaccine:

⎯ Immunosuppressed persons (cancer therapy)
⎯ Persons who develop life-threatening allergic reaction after a dose of DPT
⎯ Persons who develop encephalitis within 7 days of DPT immunizations.

CHECK FOR UNDERSTANDING (30 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 30 minutes for this activity:

Multiple Choice

1. Signs of plasma leakage usually appears after how many hours?

a. 24 hours.
b. 48 hours.
c. 72 hours.
d. 4 hours.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________.

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 Microbiology and Parasitology - Lab
Module #10 Student Activity Sheet

Name: _________________________________________________________________ Class number: _______

Section: ____________ Schedule: ________________________________________ Date: ________________

2. What is the vector of the dengue virus?

a. Male Aedes aegypti mosquito.
b. Female Aedes aegypti mosquito.
c. Any Aedes aegypti mosquito.
d. All of the above.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. There are how many serotypes of the dengue virus?

a. 2.
b. 4.
c. 6.
d. 10.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. The causative agent of diphtheria is?

a. Vibrio coma
b. Klebs-Loeffler bacillus
c. Culex Triteaniorhynchus
d. Herpes virus varicellae
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

5. A poisonous substance produced during the growth of a microorganism which is responsible for major pathologic
changes.
a. Endotoxin
b. Choleragen
c. Exotoxin
d. A and B
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

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 Microbiology and Parasitology - Lab
Module #10 Student Activity Sheet

Name: _________________________________________________________________ Class number: _______

Section: ____________ Schedule: ________________________________________ Date: ________________

2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

C. LESSON WRAP-UP (5 minutes)

AL Activity: CAT: 3-2-1

Instructions:
1. As an exit ticket at the end of the class period
2. Record three things you learned from the lesson.
3. Next, two things that you found interesting and that you’d like to learn more about.
4. Then, record one question you still have about the lesson.

Three things you learned:

1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________

Two things that you’d like to learn more about:

1. __________________________________________________________________________________
2. __________________________________________________________________________________

One question you still have:

1.___________________________________________________________________________________

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