Management of Dengue Hemorrhagic Fever - Nursing Care

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.

DHF is an acute arbovirus infection that enters the body through the bite of a mosquito species aides. The disease often strikes children, adolescents, and adults that is characterized by fever, muscle and joint pain. Symptoms such as headache, fever, exhaustion, severe joint and muscle pain, swollen glands (lymphadenopathy), and rash. The presence (the "dengue triad") of fever, rash, and headache (and other pains) is particularly characteristic of dengue fever. Nursing Diagnosis and Interventions for Dengue Hemorrhagic Fever Nursing Diagnosis 1. : Hyperthermia related to the process of dengue virus infection. Goal: Normal body temperature Outcomes: Body temperature between 36-37 0 C Muscle pain disappeared Intervention: 1. Provide / encourage patients to drink plenty of 1500-2000 cc / day (as tolerated) Rational: To replace fluids lost due to evaporation. 2. Instruct the patient to wear clothing that is thin and easy to absorb sweat. Rationale: Providing a sense of comfort and easy thin clothing absorbs sweat and does not stimulate an increase in body temperature. 3. Observation of intake and output, vital signs (temperature, pulse, blood pressure) every 3 hours once or more often. Rational: Detecting early dehydration and to know the balance of fluids and electrolytes in the body. Vital Signs is a reference to determine the patient's general condition. 4. Collaboration: intravenous fluids and appropriate drug delivery program. Rationale: Fluid replacement is essential for patients with a high body temperature. Particular drug to lower the patient's body temperature.

Nursing Diagnosis 2. : Risk for Fluid Volume Deficit related to intravascular fluid into the extravascular migration. Objective: Not happening fluid volume deficit Outcomes: Input and output balanced Vital signs within normal limits There is no sign of pre-shock Capilarry refill less than 3 seconds Intervention: 1. Monitor vital signs every 3 hours / more often. Rationale: Vital sign help identify fluctuations in intravascular fluid. 2. Observation of capillary refill. Rational: Indications adequacy of peripheral circulation. 3. Observation of intake and output. Note the color of urine / concentration. Rationale: Decrease in urine output concentrated suspected dehydration. 4. Suggest to drink 1500-2000 ml / day (as tolerated). Rational: To consume body fluids orally. 5. Collaboration: intravenous fluid administration. Rational: It can increase the amount of body fluid, to prevent shock hipovolemic.

Nursing Diagnosis 3. : Risk for Shock Hypovolemic related to excessive bleeding, intravascular fluid into the extravascular migration. Objective: Not happening hypovolemic shock Hasl criteria: Vital signs within normal limits Intervention: 1. Monitor patient's general condition. Raional: To monitor the condition of the patient during treatment, especially when there is bleeding. Nurses immediately know the signs of pre-shock / shock. 2. Observation of vital signs every 3 hours or more Rationale: Nurses need to continue to observe the vital signs to ensure there is no pre-shock / shock. 3. Explain to patients and families sign of bleeding, and immediately report if there is bleeding. Rationale: By involving the patient and family, then the signs of bleeding can be immediately identified and prompt action, and the right can be given immediately. 4. Collaboration: intravenous fluid administration. Rationale: Intravenous fluids needed to cope with the severe loss of body fluids. 5. Collaboration: examination: HB, PCV, platelets. Rationale: To determine the level of leakage of blood vessels experienced by patients and to take further action reference.

Nursing Diagnosis 4. : Risk for imbalanced Nutrition Less Than Body Requirements related to inadequate nutritional intake due to nausea and decreased appetite. Goal: Not an interruption nutritional needs. Outcomes: There are no signs of malnutrition. Shows a balanced weight. Intervention: 1. Assess nutritional history, including a preferred food. Rationale: Identify deficiencies, suspect the possibility of intervention. 2. Observation and record the patient's food intake. Rationale: Observing caloric intake / lack of quality food consumption. 3. Measure body weight per day (if possible). Rationale: Observing weight loss / observe the effectiveness of the intervention. 4. Give food a little but often and or eat between meals. Rational: little food can reduce vulnerabilities and increase input also prevent gastric distention. 5. Give and Help oral hygiene. Rationale: Increased appetite and oral input. 6. Avoid foods that stimulate and gassy. Rational: Lowering distention and gastric irritation.

Nursing Diagnosis 5. : Risk for Bleeding related to decreased blood clotting factors (thrombocytopenia) Goal: Not bleeding. Outcomes: Normal blood pressure. Normal pulse. There is no sign of further bleeding, platelets increased. Intervention: 1. Monitor signs of decreased platelets accompanied by clinical signs. Rationale: Platelet decline is a sign of blood vessel leakage, which at some stage may cause clinical signs such as epistaxis, petechia. 2. Monitor platelets every day. Rationale: With the platelets are monitored on a daily basis, it can be seen the level of vascular leak and possible bleeding experienced by the patient. 3. Instruct the patient to a lot of rest (bed rest). Rational: patient activity can lead to uncontrolled bleeding. 4. Provide information to clients and families to report any signs of bleeding such as: hematemesis, melena, epistaxis. Rational: The involvement of patients and families may help to early treatment if there is bleeding. 5. Anticipation of bleeding: use a soft toothbrush, maintain oral hygiene, apply pressure take 5-10 minutes after each

blood. Rationale: Prevent further bleeding.

Dengue Fever Dengue fever is an acute febrile disease caused by dengue virus and is spread through the medium of the Aedes aegypti mosquito, which had been infected with the dengue virus. Dengue fever is divided into two, namely:dengue fever and denguehemorrhagic fever. Denguehemorrhagic fever is a more severe form of dengue fever, bleeding and shock, which can sometimes occur that result in death. Here are the Symptoms of Dengue Fever: Sudden high fever continuously. Headache especially in the forehead. Pain in the back of the eyeball. Pain in the body or joints. Nausea / vomiting. Reddish face. Acute fever for 2-7 days, accompanied by headache, sore muscles and joints. Be accompanied by a decrease of platelets. The heat will go down in the third or fourth day. Better cure rates. Dengue Haemorrhagic Fever: Sudden high fever, accompanied by headache, pain in the back of the eyeball, sometimes abdominal pain. There are signs of a rash or red spots on the skin. Not accompanied by a cough or sore throat. Platelets and leukocytes down (less than 100,000) An increase in hematocrit (up 20 percent of normal). Bleeding in the soft tissues (nose, mouth, or gums). Plasma leakage occurs. The more leaks can cause shock. Pain in the gut are continuous. Bleeding at the nose, mouth, gums or skin bruising. Persistent vomiting, sometimes accompanied by blood. Fecal droppings are blackish in color, due to the occurrence of bleeding in internal organs. Excessive thirst. The skin is pale and cold. Decreased consciousness and somnolence. Measures that can be done Currently, the main methods used to control and prevent the occurrence of denguehemorrhagic fever is to make the eradication of the mosquito Aedes aegypti as a dengue virus spreaders. Mosquito Aedes aegypti can be indoors or outdoors. Inside the house are usually mosquitoes like to hide in dark places like closets, coat hanger, under beds, etc.. While outside the home when the mosquito Aedes aegypti is like the shade and moist. The female mosquito will usually put their eggs in water containers around homes, schools, offices, etc., where the eggs can hatch within 10 days. Therefore, measures to drain the water bath, cover the places that contain water and bury the discarded items can be a puddle of water is very important to do, not just by governments alone but by all members of society so that the mosquito Aedes aegypti can be restricted existence. Nursing Diagnosis for Dengue Fever 1. 2. 3. 4. Deficient Fluid Volume Ineffective Peripheral Tissue Perfusion Imbalanced Nutrition Less Than Body Requirements Hyperthermia