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

Nursing Diagnosis Intervention

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.