# Situation: A 40-year-old man with dengue is admitted on the fourth day of illness; his fever subsided this morning. He weighs 60 kg and has no history of heart or kidney disease. He is receiving intravenous (IV) fluids through a 20-gauge catheter in his left forearm. On day 7 he has been afebrile for 3 days and is eating well. His hematocrit has fallen from 51% to 41%, his platelet count is rising, and his urine output is large. His IV isotonic fluid is still running at the rate set on day 4. He now has puffy eyelids, mild dyspnea when lying flat, and fine crackles at both lung bases. What should the nurse do?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629902  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 40-year-old man with dengue is admitted on the fourth day of illness; his fever subsided this morning. He weighs 60 kg and has no history of heart or kidney disease. He is receiving intravenous (IV) fluids through a 20-gauge catheter in his left forearm.

On day 7 he has been afebrile for 3 days and is eating well. His hematocrit has fallen from 51% to 41%, his platelet count is rising, and his urine output is large. His IV isotonic fluid is still running at the rate set on day 4. He now has puffy eyelids, mild dyspnea when lying flat, and fine crackles at both lung bases. What should the nurse do?

## 보기

1. Report the findings so the IV rate can be reduced **✔ 정답**
2. Increase the IV rate to correct the fall in hematocrit
3. Prepare a blood transfusion for the fall in hematocrit
4. Continue the rate and recheck the hematocrit in 24 hours

**정답: 1**

## 해설

In the recovery phase of dengue, leaked plasma returns to the vessels: the hematocrit falls, urine output rises, and IV fluid still running at the critical-phase rate causes fluid overload. Puffy eyelids, orthopnea, and crackles are signs of overload, so the nurse reports them so that IV fluid can be reduced or stopped. A falling hematocrit with rising platelets and no bleeding reflects reabsorption, not blood loss.

## 심화 해설

Clinical picture

A dengue patient on day 7 has entered the recovery phase. The fever has resolved, oral intake is adequate, and the laboratory trend shows a falling hematocrit from 51% to 41% with a rising platelet count and large urine output. These are expected findings because the capillary leak that characterized the critical phase is reversing, and the fluid that had shifted into the interstitial space is now returning to the intravascular compartment.

Why the patient is overloaded

During the critical leakage phase of dengue, plasma escapes from the vessels into the tissues, which is why the hematocrit rises and intravascular volume falls. Intravenous isotonic fluid is given to maintain perfusion during that phase. Once the leak stops and reabsorption begins, the same IV fluid that was appropriate on day 4 now adds to the returning plasma volume. Continued infusion at the critical-phase rate during recovery produces iatrogenic fluid overload. The puffy eyelids, difficulty breathing when lying flat, and fine crackles at both lung bases are signs of pulmonary edema from excess circulating volume.

Interpreting the hematocrit fall

A falling hematocrit in this setting does not indicate hemorrhage. The patient has no bleeding, the platelet count is rising, and urine output is large. The drop from 51% to 41% reflects hemodilution as reabsorbed fluid re-enters the vessels, not red cell loss. Therefore, blood transfusion is not indicated, and increasing the IV rate would worsen the overload. Waiting 24 hours while continuing the current rate would also allow pulmonary edema to progress.

Nursing action

The correct response is to report the findings so the IV rate can be reduced or the infusion stopped. Key point! The same IV rate that is life-saving during the critical phase becomes dangerous in recovery. Watch out! Do not mistake the falling hematocrit for bleeding when platelets are rising and urine output is high. The nurse should assess respiratory status, elevate the head of the bed, monitor oxygen saturation, and prepare to titrate or discontinue the IV fluid as prescribed.

| Phase | Hematocrit | Urine output | IV fluid need |
| --- | --- | --- | --- |
| Critical (leakage) | Rising | Decreased | Maintain to support perfusion |
| Recovery (reabsorption) | Falling | Increased | Reduce or stop to prevent overload |

## 임상 시나리오

Dengue Recovery Phase Fluid ManagementRecognizing and responding to iatrogenic fluid overload
In the recovery phase of dengue, extravasated plasma returns to the intravascular space, causing hematocrit to fall, urine output to rise, and platelets to recover. Continued IV fluid at the critical-phase rate adds to this returning volume and produces fluid overload.

Signs of overload include puffy eyelids, orthopnea, and fine crackles at lung bases. The nurse should report these findings immediately so the IV rate can be reduced or stopped.

A falling hematocrit with rising platelets and no bleeding reflects hemodilution from reabsorption, not blood loss. Blood transfusion is not indicated, and increasing the IV rate would worsen overload.

CautionDo not interpret the hematocrit drop as hemorrhage. In recovery, the drop from 51% to 41% is expected and signals that IV fluids should be de-escalated, not increased.

## 핵심 개념

- **Dengue recovery phase** — Period after defervescence when capillary leak reverses, extravasated plasma returns to circulation, urine output rises, and hematocrit falls.
- **Fluid overload** — Excess intravascular volume causing signs such as puffy eyelids, orthopnea, and crackles; in dengue recovery it results from continued IV fluids plus reabsorbed plasma.
- **Hematocrit fall in dengue** — In recovery, a falling hematocrit with rising platelets and no bleeding reflects hemodilution from reabsorbed fluid, not hemorrhage.
- **Orthopnea** — Difficulty breathing when lying flat, a sign of pulmonary congestion from fluid overload.
- **Iatrogenic fluid overload** — Volume excess caused by medical intervention, such as continuing critical-phase IV fluid rates into the recovery phase of dengue.

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