6 Nursing Diagnosis - Care Plan for Dengue Fever

6 Nursing Diagnosis for Dengue Fever - Care Plan for Dengue Fever
Dengue haemorrhagic fever (DHF) is a disease caused by dengue virus of a virus belonging to arbovirus and entered into the patient's body through the bite of a mosquito "Aedes aegypty" (Christantie Efendy, 1995).

Dengue haemorrhagic fever (DHF) is a disease found in children and adults with primary symptoms of fever, muscle aches and joint pain accompanied by rash or without a rash. DHF is classified as a type of virus arbo virus and entered into the patient's body through the bite of a mosquito "Aedes aegypty" (female) (Seoparman, 1990).


Signs and Symptoms of Dengue Haemorrhagic Fever (DHF)

High fever for 5-7 days
Nausea, vomiting, no appetite, diarrhea, constipation.
Bleeding, especially bleeding under the skin, ptechie, echymosis, hematoma.
Epistaxis, hematemisis, melena, hematuri.
Sore muscles, joints, abdomen, and heartburn.
Headache.
Swelling around the eyes.
Enlarged liver, spleen, and lymph nodes.
Signs of shock (cyanosis, clammy skin, decreased blood pressure, anxiety, capillary refill of more than two seconds, fast and weak pulse.)


Complication of Dengue Haemorrhagic Fever

The complication of dengue fever include:

Extensive bleeding.
Shock or shock.
Effuse pleural
Impairment of consciousness.


Classification of Dengue Haemorrhagic Fever

a. Degree I:
Fever accompanied by other clinical symptoms or spontaneous bleeding, positive tourniquet test, thrombocytopenia and Hemo concentration.

b. Degree II:
Clinical manifestations of degree I with the manifestation of spontaneous bleeding under the skin like petekhie, hematoma and bleeding from other places.

c. Degree III:
Clinical manifestations of degree II, coupled with the circulation system failure was found manifestation in the form of a rapid and weak pulse, hypotension with moist skin, cold and anxious patients.

d. Degree IV:
Clinical manifestations in patients with degree III coupled with a heavy shock was found manifestations with marked tension was measured and no palpable pulse.


Nursing Assessment Nursing Care Plan for Dengue Fever

• Review the basic data, the need for bio-psycho-social-spiritual patients from various sources (patients, families, medical records and other health team members).
• Identify potential sources and available to meet patient needs.
• Review the history of nursing.
• Assess the increase in body temperature, signs of bleeding, nausea, vomiting, no appetite, heartburn, sore muscles and joints, signs of shock (rapid and weak pulse, hypotension, cold and moist skin, especially on the extremities, cyanosis , restlessness, decreased consciousness).

6 Nursing Diagnosis for Dengue Fever - Care Plan for Dengue Fever

1. Hypovolemic shock related to hemorrhage
2. Imbalanced Nutrition: Less than body requirements related to nausea, vomiting, no appetite.
3. Increased body temperature related to the process of dengue virus infection.
4. Risk for bleeding related to thrombocytopenia.
5. Deficient Fluid Volume related to increased capillary permeability, bleeding, vomiting and fever.
6. Deficient Knowledge: about the disease process related to a lack of information.

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Hyperthermia : Nursing Care Plan - Nursing Diagnosis and Nursing Interventions

Hyperthermia

Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. When the elevated body temperatures are sufficiently high, hyperthermia is a medical emergency and requires immediate treatment to prevent disability or death.

The most common causes are heat stroke and adverse reactions to drugs. Heat stroke is an acute condition of hyperthermia that is caused by prolonged exposure to excessive heat or heat and humidity. The heat-regulating mechanisms of the body eventually become overwhelmed and unable to effectively deal with the heat, causing the body temperature to climb uncontrollably. Hyperthermia is a relatively rare side effect of many drugs, particularly those that affect the central nervous system. Malignant hyperthermia is a rare complication of some types of general anesthesia.

Hyperthermia can be created artificially by drugs or medical devices. Hyperthermia therapy may be used to treat some kinds of cancer and other conditions, most commonly in conjunction with radiotherapy.

Hyperthermia differs from fever in the mechanism that causes the elevated body temperatures: a fever is caused by a change in the body's temperature set-point.

The opposite of hyperthermia is hypothermia, which occurs when an organism's temperature drops below that required for normal metabolism. Hypothermia is caused by prolonged exposure to low temperatures and is also a medical emergency requiring immediate treatment.

Signs and symptoms

Hot, dry skin is a typical sign of hyperthermia. The skin may become red and hot as blood vessels dilate in an attempt to increase heat dissipation, sometimes leading to swollen lips. An inability to cool the body through perspiration causes the skin to feel dry.

Other signs and symptoms vary depending on the cause. The dehydration associated with heat stroke can produce nausea, vomiting, headaches, and low blood pressure. This can lead to fainting or dizziness, especially if the person stands suddenly.

In the case of severe heat stroke, the person may become confused or hostile, and may seem intoxicated. Heart rate and respiration rate will increase (tachycardia and tachypnea) as blood pressure drops and the heart attempts to supply enough oxygen to the body. The decrease in blood pressure can then cause blood vessels to contract, resulting in a pale or bluish skin color in advanced cases of heat stroke. Some victims, especially young children, may have seizures. Eventually, as body organs begin to fail, unconsciousness and coma will result.


Hyperthermia

Related To :

• Infection
• Inflammation
• Dehydration
• CNS Pathology
• Exposure to heat/sun
• Impaired physical environment
• Vigorous activity

Evidenced by :

• Temperature over 37.8 C (100 F) orally, or 38.8 C (101 F) rectally.
• Malaise/weakness
• Loss of appetite
• Tachycardia
• Shivering/goose pimples
• Dehydration
• Flushed skin/li>
• Warm to touch
• Increased respiratory rate

Goal : The patient will : Maintian normal body temperature.


Nursing Interventions :

• Administer antipyretics per physician's order.
• Remove excess clothing or blankets.
• Assess possible etiology of increased temperature.
• Encourage fluids when indicated.
• Assess temperature q ___ hours.
• Provide air condition/fan if appropriate.

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