Hyperthermia and Acute Pain related to Dengue Fever Hemorrhagic (DHF)

Hyperthermia r/t Dengue Fever Hemorrhagic (DHF)
Nursing Diagnosis : Hyperthermia related to disease process (viremia)

Goal :
Patient 's body temperature can be reduced.

Outcome :
  • Comfortable body condition.
  • Temperature 36,80C-37,50C.
  • Blood pressure : 120/80 mmHg.
  • Respiration : 16-24 x / mnt.
  • Pulse : 60-100 x / mnt.

Intervention :
  • Assess the onset of fever.
  • Observation of vital signs (temperature, pulse, blood pressure, respiration) every 3 hours.
  • Instruct the patient to drink (2.5 liters / 24 hours).
  • Give warm compresses.
  • Suggest to not wear thick blankets and clothing.
  • Give intravenous fluid therapy and medications as ordered.

Rationale :
  • To identify patterns of fever.
  • Vital Signs is a reference to determine the patient's general condition.
  • The increase in body temperature results in increased evaporation body so it needs to be balanced with a high fluid intake.
  • With vasodilation can increase evaporation which accelerates the decline in body temperature.
  • Clothing thin body helps reduce evaporation.
  • Fluid administration is very important for patients with a high temperature.


Nursing Diagnosis : Acute Pain related to pathological disease process.

Goal :
Patient's pain can be reduced and disappeared.

Outcomes :
  • The patient said that the pain was reduced / lost.
  • The pain was on a scale of 0-3.
  • Blood pressure : 120/80 mmHg.
  • Temperature : 36,80C-37,50C.
  • Respiration : 16-24 x / mnt.
  • Pulse : 60-100 x / mnt.

Intervention :
  • Observation of the patient's level of pain (scale, frequency, duration).
  • Provide a quiet and comfortable environment and comfort measures.
  • Give proper entertainment activities.
  • Involve families in nursing care.
  • Teach the patient relaxation techniques.
  • Collaboration with physicians to analgesic drug delivery.

Rationale :
  • Indicates the need for intervention and also the signs of the development / resolution of complications.
  • A comfortable environment will help the process of relaxation.
  • Refocused attention ; improve the ability to cope with pain.
  • Family will help the healing process by training the patient relaxation.
  • Relaxation pain will move to other things.
  • Provide pain relief.

Signs and Symptoms of Psychiatric Disorders : Motor Behavior

Aspects of life including impulse, motivation, hope, encouragement, instinct and craving, as expressed by one's behavior or motor activity.

1. Echopraxia : Echopraxia is the involuntary repetition or imitation of another person's actions.

2. Catatonia : motor abnormalities in non-organic disorders (as opposed to a disturbance of consciousness and motor activity of secondary organic pathology).
  • Catalepsy : a general term for a position that does not move continuously maintained.
  • Catatonic furor : agitated motor activity, not intended and are not influenced by external stimulation.
  • Catatonic stupor : a real decrease in motor activity, often to the point of immobility and seemed unaware of surroundings.
  • Catatonic Rigidity : acceptance of a rigid posture conscious, against attempts to be moved.
  • Catatonic posturing : acceptance inappropriate posture or rigid conscious, usually maintained for a long time.
  • Flexibility cerea (waxy flexibility) : Waxy flexibility is a psychomotor symptom of catatonic schizophrenia which leads to a decreased response to stimuli and a tendency to remain in an immobile posture.

3. Negativism : detention without motivation against any attempt to move or to all instructions.

4. Cataplexy : cataplexy is a sudden and transient episodes of muscle weakness accompanied by full conscious awareness, typically triggered by emotions such as laughing, crying, terror, etc.

5. Stereotypies : A stereotypy is a repetitive or ritualistic movement, posture, or utterance. Stereotypies may be simple movements such as body rocking, or complex, such as self - caressing, crossing and uncrossing of legs, and marching in place.

6. Mannerism : the movement is not realized, and are habitual.

7. Automatism : action or automatic actions that usually represents a symbolic activity that is not realized.

8. Command automatism : automatism follow the suggestion (also called automatic compliance).

9. Mutism : silent without structural abnormalities .

10. Overactivity :
  • Psychomotor agitation : overactivity of motor and cognitive overload, usually not productive and as a result of a response to the tension in the (inner tension).
  • Hyperactivity / hyperkinesis : anxiety and destructive activity, often accompanied by the basic pathology in the brain.
  • Tick : motor movements are spasmodic and unconscious.
  • Sleep walking ( somnambulisme ) : motor activity while asleep.
  • Akathisia : subjective feelings of tension to the motor as a side effect of antipsychotic medications, or other medications that can cause anxiety ; sitting and standing are alternated repeated and repeated ; can be misinterpreted as psychotic agitation.
  • Compulsion : uncontrollable impulse to perform repetitive actions.
Dipsomania : compulsion to drink alcohol.
Kleptomania : compulsion to steal.
Nymphomaniac.
Satiriasis.
Trichotillomania : compulsion to pull out hair.
Ritual : automatic compulsive activity in nature, lowering the original anxiety.
  • Ataxia : failure of muscle coordination, muscle movement irregularities.
  • Polyphagia : pathological overeating.

11. Hypo - activity / hypo - kinesis : motor activity and cognitive decline , such as psychomotor retardation ; slowing the mind , speech and movement that can be seen .

12. Mimicry : artificial and simple motor activity in children .

13. Aggression : stronger and directed action goals that may be verbal or physical ; motor part of the affective violence , anger or hostility .

14. Acting ( acting out ) : the direct expression of a hope or an unconscious impulse in the form of movement ; unconscious fantasy turned impulsively in behavior .

15. Abulia : decrease impulse to act and think , accompanied by indifference about the consequences of actions ; accompanied by neurological deficits .

16. Vagaboundage : like wandering the streets aimlessly .

Mental State Examination : Affect and Mood


Affect and Mood

A complex feeling state with psychic, somatic and behavioral components related to
affective and mood.

Affect

Afek is a visible expression of emotion ; may not be consistent with the emotions that said the patient.
  1. Appropriate Affect : emotional rhythm harmonious conditions ( corresponding, synchronized) with the idea, thought or conversation that accompanies ; further described as a wide or full affect, in which a complete emotional range expressed accordingly.
  2. Inappropriate Affect : disharmony between the emotional rhythm with ideas, thoughts or conversation.
  3. Blunted Affect : the affective disorders manifested by severe decline in the intensity of feeling expressed rhythm out.
  4. Restricted or constricted Affect : reduction in the intensity of the rhythm feeling less severe than the effects of blunt but clearly decreased.
  5. Fiat Affect : no or almost no signs of affective expression ; monotonous voice, a face that does not move.
  6. Labile Affect : feeling rhythm changes quickly and abruptly, which is not related to external stimulation.

Mood

Mood is an emotion that permeated maintained, subjectively experienced and reported by patients and seen by others. Examples are depression, elasi, anger.
  1. Dysphoric mood : an unpleasant mood.
  2. Euthymic Mood : mood within the normal range, suggesting the presence of depressed mood or soar.
  3. Expansive mood : the expression of one's feelings without limitation, often with exaggerated assessment of the person's interest or significance.
  4. Irritable mood : the feeling caused by the expression disturbed or angered easily.
  5. Labile mood : oscillation between euphoria and depression or angered.
  6. Elevated mood : atmosphere of confidence and pleasure ; a more cheerful mood than usual.
  7. Euphoria : elasi strong feeling of greatness.
  8. Ecstasy : a strong sense of excitement.
  9. Depression : feelings of sadness that psychopathological.
  10. Anhedonia : loss of interest and withdraw from all routine activities and fun, often accompanied by depression.
  11. Grief ( mourning ) : sadness in accordance with the real loss.
  12. Alexitimia : inability or difficulty in describing or being aware of one's emotions or mood.

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