# Situation: The nurse is assigned to an adult intensive care unit where several clients have multi-system problems. Each item describes a different client. A 19-year-old weighing 50 kg is on day 5 of confirmed dengue. Her fever ended this morning. She has received no fluid bolus since admission. Her findings are: 08:00 — temperature 38.6 °C, blood pressure 110/78 mmHg, heart rate 96/min, hematocrit 41%, platelets 110,000/µL, capillary refill 2 seconds 14:00 — temperature 36.9 °C, blood pressure 104/88 mmHg, heart rate 118/min, hematocrit 49%, platelets 42,000/µL, capillary refill 3 seconds Which conclusion is correct?

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> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: The nurse is assigned to an adult intensive care unit where several clients have multi-system problems. Each item describes a different client.

A 19-year-old weighing 50 kg is on day 5 of confirmed dengue. Her fever ended this morning. She has received no fluid bolus since admission. Her findings are:
08:00 — temperature 38.6 °C, blood pressure 110/78 mmHg, heart rate 96/min, hematocrit 41%, platelets 110,000/µL, capillary refill 2 seconds
14:00 — temperature 36.9 °C, blood pressure 104/88 mmHg, heart rate 118/min, hematocrit 49%, platelets 42,000/µL, capillary refill 3 seconds
Which conclusion is correct?

## 보기

1. Fluid overload of the recovery phase; fluids should be reduced
2. Compensated shock from plasma leakage, despite a normal systolic **✔ 정답**
3. Recovery, since the fever has settled and systolic pressure is normal
4. Bleeding, since the platelets are falling and need a transfusion

**정답: 2**

## 해설

The fall of fever marks the critical phase of dengue, when plasma leakage can cause shock. A hematocrit rising from 41% to 49% with a rapid fall in platelets shows hemoconcentration from leakage, and a pulse pressure narrowed to 16 mmHg with tachycardia and slower capillary refill shows compensated shock, even though systolic pressure is still normal. She needs prompt fluid resuscitation per dengue protocol.

## 심화 해설

Clinical context The client is on day 5 of confirmed dengue, and the fever has just settled. In dengue, defervescence does not mean the illness is over — it often signals the beginning of the critical phase, when plasma leakage peaks and shock can develop over hours.

Interpreting the trend The key is to compare the two time points. At 08:00, the hematocrit was 41% and platelets were 110,000/µL. By 14:00, the hematocrit had climbed to 49% while platelets dropped to 42,000/µL. A rising hematocrit of this magnitude — an 8-point jump in 6 hours — is hemoconcentration, not a laboratory error. It means plasma is leaking out of the intravascular space while red cells remain behind, making the blood more concentrated.

Why this is compensated shock The blood pressure reading of 104/88 mmHg may look acceptable if only the systolic is considered. However, the pulse pressure is only 16 mmHg (104 minus 88). A pulse pressure below 20 mmHg is a hallmark of narrowed pulse pressure in dengue shock, reflecting reduced stroke volume from intravascular depletion. The heart rate has also risen from 96/min to 118/min, and capillary refill has slowed from 2 seconds to 3 seconds. These compensatory responses — tachycardia and peripheral vasoconstriction — are the body’s attempt to maintain systolic pressure despite falling plasma volume. The systolic remains normal because compensation is still working, but the patient is already in compensated shock.

Pathophysiology of the critical phase Dengue shock syndrome arises when critical plasma leakage produces hemodynamic compromise. The challenge in management is that fluid therapy must balance the risk of hypoperfusion against the risk of volume overload, because the leaked plasma can rapidly return to the circulation during the recovery phase [1]. In this client, the absence of any prior fluid bolus makes hypovolemia the dominant concern. The combination of hemoconcentration, narrowed pulse pressure, tachycardia, and delayed capillary refill points directly to plasma leakage, not to fluid excess.

Ruling out the other options

| Option | Why it is incorrect |
| --- | --- |
| 1. Fluid overload of recovery phase | Fluid overload would present with falling hematocrit, widened pulse pressure, hypertension or signs of pulmonary edema. This client shows the opposite: rising hematocrit and narrowed pulse pressure. |
| 3. Recovery | Defervescence alone does not indicate recovery. The rising hematocrit, falling platelets, tachycardia, and narrowed pulse pressure all indicate worsening plasma leakage, not convalescence. |
| 4. Bleeding requiring transfusion | Thrombocytopenia is expected in dengue and does not by itself mandate platelet transfusion. Transfusion is reserved for significant clinical bleeding, not a platelet count alone. The primary problem here is plasma leakage, not hemorrhage. |

Clinical priority Key point! The client requires prompt fluid resuscitation according to dengue protocol. In compensated shock, isotonic crystalloid is initiated and the response is monitored through serial hematocrit, vital signs, urine output, and perfusion markers. Watch out! A normal systolic blood pressure can be falsely reassuring in early dengue shock. Always calculate the pulse pressure and track the hematocrit trend when fever subsides.

Monitoring perspective Continuous, non-invasive monitoring has been explored to stratify risk in hospitalized dengue patients, because clinical deterioration can occur rapidly during the critical phase . Wearable photoplethysmography may help detect early hemodynamic changes, but at the bedside, the most reliable indicators remain the trend in hematocrit, pulse pressure, heart rate, and capillary refill. Severe dengue, including dengue shock syndrome, involves plasma leakage with potential progression to bleeding and organ dysfunction, which is why early recognition of compensated shock is a high-stakes nursing judgment .
References (research sources)

- [1]An artificial intelligence-based approach to identify volume status in patients with severe dengue using wearable PPG data.Research articleLyle NN, Chanh HQ, Nguyen Van H, Anibal J, Karolcik S, Ming D, Nguyen Thi G, Vu Ngo Thanh H, Nguyen Quang H, Ho Bich H, Le Dinh Van K, Tu VHM, Nguyen Quoc KP, Trieu HT, Phan QT, Phan Vinh T, Luong Thi Hue T, Georgiou P, Thwaites L, Yacoub S, Vietnam ICU Translational Applications Laboratory (VITAL) investigators. (2025) · DOI: 10.1371/journal.pdig.0000924

## 임상 시나리오

Dengue Critical Phase RecognitionDefervescence is the danger signal, not the all-clear
When fever settles around day 3–7, assume the critical phase has begun. Monitor for plasma leakage every 1–2 hours using serial hematocrit, pulse pressure, and perfusion markers.

A rising hematocrit with falling platelets indicates hemoconcentration from leakage. A pulse pressure below 20 mmHg, tachycardia, and prolonged capillary refill indicate compensated shock even when systolic pressure remains normal.

CautionDo not wait for hypotension. Begin fluid resuscitation with isotonic crystalloid per dengue protocol as soon as compensated shock is recognized. Falling platelets alone are not an indication for platelet transfusion.

## 핵심 개념

- **Compensated shock** — Early stage of shock in which systolic blood pressure is maintained by compensatory mechanisms such as tachycardia and vasoconstriction, despite reduced tissue perfusion.
- **Hemoconcentration** — Rising hematocrit caused by plasma leakage out of the intravascular space, leaving red blood cells more concentrated.
- **Pulse pressure** — Difference between systolic and diastolic blood pressure; narrowing below 20 mmHg in dengue suggests reduced stroke volume from plasma leakage.
- **Critical phase of dengue** — Period around defervescence, typically days 3–7, when plasma leakage peaks and shock or organ impairment may develop.
- **Plasma leakage** — Movement of plasma from the intravascular compartment into extravascular spaces due to increased capillary permeability in dengue.

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