Dengue hemorrhagic fever is a severe febrile disease that is often lethal, caused by a virus, characterized by capillary permeability, abnormalities of hemostasis and in severe cases, shock syndrome protein loss. (Nelson, 2000: 1134)
Symptoms of Dengue Fever
- High fever for 5-7 days.
- Nausea, vomiting, no appetite, diarrhea, constipation.
- Bleeding, especially bleeding under the skin, ptechie, echymosis, hematoma.
- Epistaxis, hematemesis, melena, hematuria.
- Muscle pain, joint, abdoment, and heartburn.
- Headache.
- Swelling around the eyes.
- Enlargement of the liver, spleen, and lymph nodes.
- Signs of shock (cyanosis, clammy skin, decreased blood pressure, anxiety, capillary refill more than two seconds, rapid and weak pulse).
Nursing Diagnosis and Nursing Intervention for DHF
1. Imbalanced Body Temperature
related to :
Goal :
Nursing Interventions and Rational for DHF :
1. Assess the onset of fever.
Rational: to identify patterns of fever patients.
2. Observation of vital signs (temperature, pulse, blood pressure, respiration) every 3 hours.
Rational: vital signs is a reference to determine the patient's general condition.
3. Instruct patient to drink plenty
Rationale: Increased body temperature resulting in increased evaporation of the body so it needs to be balanced with a lot of fluid intake.
4. Give a warm compress.
Rational: With vasodilation can increase evaporation which accelerate the decline in body temperature.
5. Advise not to wear a thick blanket and clothing.
Rational: thin clothing helps reduce the evaporation of the body.
6. Give intravenous fluid therapy and medications according to physician programs.
Rational: infusion of fluids is very important for patients with a high temperature.
- Normal body temperature (36-37 C).
- Patients were free from fever.
Nursing Interventions and Rational for DHF :
1. Assess the onset of fever.
Rational: to identify patterns of fever patients.
2. Observation of vital signs (temperature, pulse, blood pressure, respiration) every 3 hours.
Rational: vital signs is a reference to determine the patient's general condition.
3. Instruct patient to drink plenty
Rationale: Increased body temperature resulting in increased evaporation of the body so it needs to be balanced with a lot of fluid intake.
4. Give a warm compress.
Rational: With vasodilation can increase evaporation which accelerate the decline in body temperature.
5. Advise not to wear a thick blanket and clothing.
Rational: thin clothing helps reduce the evaporation of the body.
6. Give intravenous fluid therapy and medications according to physician programs.
Rational: infusion of fluids is very important for patients with a high temperature.
2. Activity Intolerance
related to
weak body condition
Goal :
1. Assess the patient's complaint.
Rationale: To identify patient's problems.
2. Review of the things that are not capable or able to be done by the patient.
Rationale: To determine the level of dependency of patients in meeting their needs.
3. Help the patient to meet their daily activities according to the limitations of the patient.
Rationale: The provision of assistance is needed by the patient at the time his condition is weak and nurses have a responsibility in fulfilling their daily needs without dependence on patient care.
4. Put the items in places easily accessible by patients.
Rationale: Will assist patients to meet their own needs without help from others.
Goal :
- Patients are able to independently after fever-free.
- Activities of daily needs are met
1. Assess the patient's complaint.
Rationale: To identify patient's problems.
2. Review of the things that are not capable or able to be done by the patient.
Rationale: To determine the level of dependency of patients in meeting their needs.
3. Help the patient to meet their daily activities according to the limitations of the patient.
Rationale: The provision of assistance is needed by the patient at the time his condition is weak and nurses have a responsibility in fulfilling their daily needs without dependence on patient care.
4. Put the items in places easily accessible by patients.
Rationale: Will assist patients to meet their own needs without help from others.
