Nursing Assessment for Dengue Hemorrhagic Fever

Dengue Haemorrhagic Fever (DHF) is a disease caused by the dengue virus which is transmitted through the bite of Aedes aegypti and Aedes albopictus which causes disturbances in capillary blood vessels and the blood clotting system, resulting in bleeding.

Dengue hemorrhagic fever (DHF) is a specific syndrome that tends to affect children under 10 years of age. It causes abdominal pain, hemorrhage (bleeding), and circulatory collapse (shock).

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 Assessment for Dengue Hemorrhagic Fever.

Assessment

a. Subjective data

• Weak.
• Heat or fever.
• Headache.
• Anorexia, nausea, thirst, painful swallowing.
• Heartburn.
• Pain in the muscles and joints.
• Stiffness throughout the body.
• Constipation.

b. Objective data

• High body temperature, shivering, redness of the face looks.
• Dry oral mucosa, bleeding gums, tongue dirty.
• Red spots appear on the skin (petechiae), torniquet test (+), epistaxis, ecchymosis,
• Hyperemia of the throat.
• Epigastric tenderness.
• On palpation palpable enlarged liver and spleen.
• On shock (degree IV) rapid and weak pulse, hypotension, cold extremities, restlessness, peripheral cyanosis, shallow breathing.

Laboratory tests in DHF will be found:

• Ig G positive dengue.
• Thrombocytopenia.
• Hemoglobin increase> 20%.
• Hemoconcentration (hematocrit increased).
• Blood chemistry workup showed hypoproteinemia, hyponatremia, hypochloremic.

On day 2 and 3 occur leukopenia, neutropenia, aneosinofilia, increased lymphocytes, monocytes, and basophils

• SGOT / SGPT may be increased.
• Urea and blood pH may be elevated.
• Bleeding time elongated.
• Metabolic acidosis.
• On urine examination found mild albuminuria.

4 Nursing Diagnosis Interventions for Dengue Hemorrhagic Fever

Nursing Diagnosis and Interventions for Dengue Hemorrhagic Fever
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

1. Deficient Fluid Volume related to increased capillary permeability, bleeding, vomiting, and fever.
2. Ineffective Peripheral Tissue Perfusion related to bleeding.
3. Imbalanced Nutrition Less Than Body Requirements related to nausea, vomiting, no appetite.
4. Hyperthermia related to the process of viral infection.

3. Nursing Interventions for DHF – Dengue Hemorrhagic Fever
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

1. Deficient Fluid Volume

• 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

2. Ineffective Peripheral Tissue Perfusion

•  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)

3. Imbalanced Nutrition Less Than Body Requirements

• 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

4. Hyperthermia

• Measure vital signs: body temperature
• Teach the family in the temperature measurement
• Perform wipe
• Increase fluid intake
• Provide therapy to lower the temperature