Risk for Hypovolemic Shock, Risk for Metabolic Acidosis and Self-care Deficit


Nursing Diagnosis : Risk for Hypovolemic Shock related to continuous bleeding.

Goal :
  • Shock does not occur during the treatment period.
Expected Outcomes:
  • Not decreased consciousness.
  • Vital signs within normal limits.
  • Good skin turgor.
  • Good peripheral perfusion (acral warm, dry and red).
  • Fluid balance in the body.

Nursing Interventions :
1. Encourage the patient to drink more.
R /: Increased fluid intake, may increase intravascular volume, which can increase tissue perfusion.

2. Observation of vital signs every 4 hours.
R /: Changes in vital signs can be an early indicator of dehydration.

3. Observation of the signs of dehydration.
R /: Dehydration is the beginning of the syock if dehydration is not in good hands.

4. Observation of fluid intake and output.
R /: adequate fluid intake can compensate for excessive discharge.

5. Collaboration in:
  • Intravenous fluids or transfusion.
  • Giving coagulant and uterotonic.
  • CVP custom installation.
  • Examination of the plasma density.

Nursing Diagnosis : Risk for Metabolic Acidosis related to a decrease in the amount of blood in the capillaries.

Goal :
Metabolic acidosis did not occur during the treatment period,

Expected Outcomes:
  • The results of blood gas analysis within normal limits.
  • Vital signs within normal limits.
Nursing Interventions :
1. Observation vital signs within normal limits.
R /: Changes in vital signs is an early sign of detection of acidosis.

2. Encourage and motivate patients to drink sweet.
R /: Reducing protein breakdown and excessive fat to meet metabolic needs.

3. Collaboration in:
  • BGA inspection.
  • Intravenous fluids.

Nursing Diagnosis : Self-care Deficit related to physical weakness

Goal :
During the treatment period of daily activity needs are met.

Nursing Interventions :
1. Explain to the patient about the importance of maintaining personal hygiene.
R /: Adequate knowledge enables clients cooperatively towards the maintenance action performed.

2. Assist the client in meeting the nutritional needs (food and drink).
R /: Weakness of the body requires that the client needs with the help of others.

3. Assist the client in meeting the needs of personal hygiene.
R /: Weakness of the body that occur can lead to inability to meet the needs of personal hygiene.

4. Observation fulfillment daily activities.
R / Increased ability fulfillment of daily needs may reflect reduced body weakness.

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 .