1. Nursing Assessment
- Assess the patient’s medical history
- Assess the increase in body temperature, signs of bleeding, nausea, vomiting, no appetite, heartburn, muscle pain and signs of shock (rapid and weak pulse, hypotension, skin cold and moist, especially on the extremities, cyanosis, restlessness, decreased awareness).
2. Nursing Diagnosis for DHF – Dengue Hemorrhagic Fever
- Deficient Fluid Volume related to increased capillary permeability, bleeding, vomiting, and fever.
- Ineffective Peripheral Tissue Perfusion related to bleeding.
- Imbalanced Nutrition Less Than Body Requirements related to nausea, vomiting, no appetite.
- Hyperthermia related to the process of viral infection.
Goal:
- Show signs of liquid fulfillment
- Shows signs of adequate peripheral tissue perfusion
- Showed vital signs within normal limits
- The family suggests that adaptive coping
- Observation of vital signs at least every 4 hours
- Monitor the increasing signs of dehydration: inelastic turgor, sunken fontanel, decreased urine production
- Observation and recording intake and output
- Provide adequate hydration according to the needs of the body
- Monitor laboratory values: electrolyte / blood, urine specific gravity, serum body
- Maintain adequate intake and output
- Monitor and record the weight
- Monitor the provision of intravenous fluids per hour through
- Assess and record vital signs (quality and frequency of pulse, blood pressure, capillary refill)
- Assess and record the circulation in the extremities (temperature, humidity and color)
- Assess the possibility of the death of tissue in the extremities such as cold, pain, swelling of the feet)
- Allow the child to eat foods that can be tolerated child. Plan to improve the nutritional quality at the child’s appetite increases.
- Give the food is accompanied by a nutritional supplement to improve the quality of nutritional intake
- Encourage parents to provide food with a small portion technique but often
- Measure weight every day at the same time and with the same scale
- Keep the patient’s oral hygiene
- Explain the importance of adequate intake nutirisi to cure disease
- Measure vital signs: body temperature
- Teach the family in the temperature measurement
- Perform wipe
- Increase fluid intake
- Provide therapy to lower the temperature