Dengue Hemorrhagic Fever - Nursing Care
Assessment
1. Identity
Dengue Hemorrhagic Fever is a tropical disease that often leads to the death of children, adolescents and adults (Effendy, 1995).
2. Main complaint
Patients complain of heat, headache, weakness, heartburn, nausea and decreased appetite.
3. History of present illness
Medical history showed headache, muscle aches, the whole body aches, pain on swallowing, weakness, heat, nausea, and decreased appetite.
4. History of previous illness
There is no a specific illness.
5. Family history of disease
History of Dengue Hemorrhagic Fever disease in other family members is crucial, due to Dengue Hemorrhagic Fever disease is a disease that can be transmitted through mosquito bites aigepty aides.
6. Environmental Health History
Usually less than clean environment, many puddles of water like tin cans, old tires, a water bird that rarely changed the water, the tub is rarely cleaned.
7. Developmental History
Nursing Management of Dengue Hemorrhagic Fever
1. Hyperthermia related to the dengue virus infection
Goal: Normal body temperature
Expected outcomes: The body temperature between 36-37 0C, muscle pain disappeared.
Intervention:
1. Assess the patient's body temperature
Rational: find an increase in body temperature, facilitate intervention.
2. Give warm compresses
Rational: reduce heat to heat transfer by conduction. Warm water is slowly control the heat removal without causing hypothermia or shivering.
3. Provide / encourage patients to drink plenty of 1500-2000 cc / day (as tolerated).
Rationale: To replace fluids lost due to evaporation.
4. Instruct patient to wear clothes that are thin and easy to absorb sweat.
Rationale: To provide a sense of comfort and wear thin easily absorbs sweat and does not stimulate an increase in body temperature.
5. Observation intake and output, vital signs (temperature, pulse, blood pressure) once every 3 hours or as indicated.
Rationale: Early Detect hydrated and knowing fluid and electrolyte balance in the body. Vital Signs is a reference to determine the patient's general condition.
6. Collaboration: intravenous fluid and drug delivery according to the program.
Rationale: Proper hydration is very important for patients with a high body temperature. Particular drug to lower a patient's body heat.
2. Risk for fluid volume deficit related to intravascular fluid into the extravascular migration.
Goal: Not voume fluid deficit
Expected outcomes: Input and output balanced, vital sign within normal limits, no sign of pre-shock.
Intervention:
1. Monitor vital sign every 3 hours / as indicated.
Rationale: Vital sign helps identify fluctuations in intravascular fluid.
2. Observation of capillary refill.
Rational: Indications adequacy of peripheral circulation.
3. Observation intake and output. Note the color of urine / concentration
Rationale: Decreased urine output with increased density concentrated suspected dehydration.
4. Encourage to drink 1500-2000 ml / day (as tolerated)
Rationale: To meet the needs of the body fluids peroral
5. Collaboration: Intravenous Fluid
Rational: It can increase the amount of body fluid, to prevent hipovolemic shock.
3. Risk for Shock Hypovolemic related to excessive bleeding, intravascular fluid into the extravascular migration.
Goal: Not happening hypovolemic shock.
Expected outcomes: Vital signs within normal limits.
Intervention:
1. Monitor the patient's general condition
Rationale: To monitor the condition of the patient during treatment, especially when paused bleeding. Nurses immediately know the signs of pre-shock / shock.
2. Observation of vital sign every 3 hours or more
Rationale: Nurses need to continue to observe the vital sign to ensure it does not happen pre-shock / shock.
3. Explain to the patient and family sign of bleeding, and immediately report if bleeding occurs
Rationale: By involving the patient and family the signs of bleeding can be quickly identified and appropriate action is fast and can be immediately given.
4. Collaboration: Intravenous Fluid
Rationale: Intravenous fluids needed to overcome a severe loss of body fluids.
5. Collaboration: checks: HB, PCV, platelet
Rationale: To determine the level of blood vessel leakage experienced by patients and to take further action reference.
4. Risk for imbalanced Nutrition, Less Than Body Requirements related to inadequate nutritional intake due to nausea and decreased appetite.
Goal: No disruption nutritional needs.
Expected outcomes: There are no signs of malnutrition, indicating a balanced weight.
Intervention:
1. Review the history of nutrition, including food preferences
Rationale: Identify deficiencies, suspect the possibility of intervention.
2. Observation and record the patient's food intake
Rational: Supervise caloric intake / lack of quality food consumption.
3. Measure body weight each day (if possible)
Rational: Supervise weight loss / oversee the effectiveness of interventions.
4. Give food a little but often and or eating between meals
Rational: little food can reduce vulnerabilities and increase input also prevent gastric distention.
5. Give and oral hygiene aids.
Rationale: Increased appetite and input peroral
6. Avoid foods that stimulate and gassy.
Rationale: Reducing distention and gastric irritation.
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