2. Critical/Leakage phase

0000000Most of the admitted cases are more severe patients who cannot have adequate oral intake. Whether anorexia and/or vomiting during the critical/leakage phase.
(a) General management of patients

• Put all dengue patients together in the dengue ward or dengue corner for close observation. This ward should have mosquito net to prevent nosocomial dengue transmission.
  
• Vital signs should be measured q 1 - 2 hours; if unstable vital signs are present, it should be done more frequently, i.e. q 10 - 15 minutes.
  
• Hct should be done q 4 - 6 hours; if unstable vital signs and suspected internal bleeding, more frequently, i.e. q 0 - 1 hour. This is very critical, especially in cases with concealed bleeding.
  
• Record intake/output.
  
• Should have flow chart at bedside for recording clinical sings and symptoms, vital signs, Hct, intake/output, which is very important for adjusting the rate and type of fluid therapy.
  
• Give oxygen via face mask/nasal canular in cases with shock.
  
• Stop bleeding by proper methods, e.g. nasal packing in cases with epistaxis.
  
• Avoid unnecessary invasive procedures, e.g. do not insert naso-gastric tube in cases with upper GI bleeding.
  
• Closely observe the patients by both physicians and nurses.
  

(b) High risk patients

00000000The following types of patients are at risk, so nurses should notify attending staff as soon as possible. These patients need special laboratory investigations for they may gave complications, e.g. internal bleeding, hypoglycemia, electrolyte imbalance (hyponatremia, hypocalcemia), metabolic acidosis, liver failure and renal failure. (The lab. Investigations include, Hct, blood sugar, electrolyte + Ca, capillary or venous blood gas, coagulogram, liver function test, BUN and creatinine). These patients are:

• Young infants <1-year old.
  
• DHF grade IV or prolonged shock.
  
• Overweight patients.
  
• Patients with massive bleeding.
  
• Patients with changes of consciousness (encephalopathy).
  
• Patients with underlying diseases, e.g. thalassemia, G-6-PD deficiency, congenital heart disease, etc.
  
• Referred patients.