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.